Ethics in the intensive care unit: Informed consent
- Douglas B White, MD, MAS
Douglas B White, MD, MAS
- Vice Chair and Professor of Critical Care Medicine; Director, Program on Ethics and Critical Care Medicine
- University of Pittsburgh School of Medicine
Informed consent is a process of communication between a clinician and a patient or surrogate decision-maker that results in the patient/surrogate agreeing (or refusing) to undergo a specific medical intervention. Consent for specific aspects of medical treatment is a relatively new concept in medical ethics, having evolved over the last century. Medical decision-making previously occurred under a model that assumed that clinicians, given their technical medical expertise, could adequately know what was good for their patients without consulting them. This model was criticized because it fails to adequately account for the fact that there is often more than one reasonable treatment option, patients may choose different options depending on their values, and clinicians are generally not well-positioned to know what individual patients most value [1-3]. Moreover, it does not adequately acknowledge the importance of manifesting respect for patients as persons, which in the medical context entails efforts to allow patients to choose what happens to their bodies.
During the mid-1980s, this paternalistic model gave way to a model that placed more value on efforts to respect patient autonomy. Ideally, this was achieved through effective conversations in which patients were given enough information about the available treatment options so that they could choose the one that best matched their values and preferences. However, this ideal of patient engagement was sometimes misinterpreted as a call to let patients choose any therapy they desired, without advice from clinicians, out of a concern that such advice might inappropriately influence the patient and thereby infringe on patient autonomy. An all-too-common scenario in intensive care units (ICUs) in this era was one in which patients or surrogates were confronted with an open-ended request from the medical team such as "What do you want us to do?" without a clear explanation of options and or input from the clinician. Consequently, under-informed patient/surrogates often responded with the understandable request to "do everything," which clinicians mistakenly accepted as autonomous guidance that must be followed even if the clinician thought the patient's choice was mistaken.
It is increasingly recognized that expert advice can enhance rather than impede patients' ability to make autonomous choices that reflect their values and preferences. As a result, norms are shifting toward a truly shared approach to decision making in which both the clinician and the patient/surrogate are active participants in deliberations [4-6].
Ethical issues related to informed consent in the ICU are reviewed here. Our emphasis is on informed consent for medical interventions such as arterial catheterization, central venous catheterization, bronchoscopy, endotracheal intubation, and thoracentesis. Although many principles also apply to informed consent for surgery and participation in clinical research, these areas are beyond the scope of this review. Ethical issues related to withholding life support, withdrawing life support, and requests for futile or inappropriate therapy are discussed separately. (See "Withholding and withdrawing ventilatory support in adults in the intensive care unit" and "Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults".)
JUSTIFICATION FOR INFORMED CONSENT
The primary ethical justification for obtaining informed consent from patients is to respect their right to determine what happens to their bodies (ie, respect for autonomy). This entails a right to approve or refuse treatments that clinicians judge to be medically reasonable. It is important to note that this is a narrower right than a right to demand any medical intervention, regardless of whether the clinician believes it is medically reasonable.
- Schneiderman LJ, Kaplan RM, Pearlman RA, Teetzel H. Do physicians' own preferences for life-sustaining treatment influence their perceptions of patients' preferences? J Clin Ethics 1993; 4:28.
- Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic status and risk for substandard medical care. JAMA 1992; 268:2383.
- Blendon RJ, Aiken LH, Freeman HE, Corey CR. Access to medical care for black and white Americans. A matter of continuing concern. JAMA 1989; 261:278.
- Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996; 125:763.
- Prendergast TJ. Resolving conflicts surrounding end-of-life care. New Horiz 1997; 5:62.
- Kon AA, Davidson JE, Morrison W, et al. Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med 2016; 44:188.
- Brudney D. Choosing for another: beyond autonomy and best interests. Hastings Cent Rep 2009; 39:31.
- Puchalski CM, Zhong Z, Jacobs MM, et al. Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Hospitalized Elderly Longitudinal Project. J Am Geriatr Soc 2000; 48:S84.
- Devita M, Grenvik A. Foregoing life-sustaining therapy in intensive care. In: Textbook of Critical Care, Ayres S, Grenvik A, Holbrook P, Shoemaker W (Eds), WB Saunders, Philadelphia 1995. p.1802.
- Schenker Y, Meisel A. Informed consent in clinical care: practical considerations in the effort to achieve ethical goals. JAMA 2011; 305:1130.
- Terranova G, Ferro M, Carpeggiani C, et al. Low quality and lack of clarity of current informed consent forms in cardiology: how to improve them. JACC Cardiovasc Imaging 2012; 5:649.
- Rothberg MB, Sivalingam SK, Ashraf J, et al. Patients' and cardiologists' perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med 2010; 153:307.
- Schenker Y, Fernandez A, Sudore R, Schillinger D. Interventions to improve patient comprehension in informed consent for medical and surgical procedures: a systematic review. Med Decis Making 2011; 31:151.
- Berg JW, Appelbaum PS, Lidz CW, Parker LS. Informed Consent: Legal Theory and Clinical Practice, 2nd ed, Oxford University Press, New York 2001.
- Arnold RM, Kellum J. Moral justifications for surrogate decision making in the intensive care unit: implications and limitations. Crit Care Med 2003; 31:S347.
- Davis N, Pohlman A, Gehlbach B, et al. Improving the process of informed consent in the critically ill. JAMA 2003; 289:1963.
- Schweickert W, Hall J. Informed consent in the intensive care unit: ensuring understanding in a complex environment. Curr Opin Crit Care 2005; 11:624.
- Manthous CA, DeGirolamo A, Haddad C, Amoateng-Adjepong Y. Informed consent for medical procedures: local and national practices. Chest 2003; 124:1978.
- JUSTIFICATION FOR INFORMED CONSENT
- EMERGENCY EXCEPTION TO THE REQUIREMENT FOR INFORMED CONSENT
- PROCESS OF INFORMED CONSENT
- Assess decision-making capacity
- Discuss pertinent information
- Assess comprehension
- Ensure voluntariness
- Deliberate jointly and obtain consent
- FOREIGN LANGUAGE SPEAKERS
- APPROACHES TO INFORMED CONSENT
- ACTUAL PRACTICE IN ICUS
- SUMMARY AND RECOMMENDATIONS