When Frail Individuals or Their Families Request Nonindicated Interventions: Usefulness of the Four‐Box Ethical Approach

Abstract

In the age of person-centered care, there is an emphasis on promoting patient autonomy and surrogate decision maker authority in making treatment decisions that are aligned with the patient's priorities and values. As technological advances offer multiple clinical options with various levels and types of risks and benefits, person-centered clinical practice encourages the incorporation of patients' and families' heterogeneous experiences into decisions regarding illness management. In caring for frail elderly adults, clinicians are sometimes faced with situations in which individuals and their surrogate decision-makers request a treatment that the clinicians feel is clinically inappropriate. This article provides a case example of a frail older adult with advanced chronic kidney disease who requests dialysis despite the advice of his nephrologist to pursue conservative management. The four-box approach, which provides clinicians with a structured ethical framework to facilitate informed and ethically justified treatment decisions, is then introduced. By considering the patient's medical indications, preferences, quality of life, and contextual factors, how each consideration plays a unique yet equally important role in informing clinically responsible and person-centered care is illustrated.

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