Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults
- 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
- Section Editors
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
- Robert M Arnold, MD
Robert M Arnold, MD
- Editor-in-Chief — Palliative Care
- Section Editor — General Principles of Palliative Care
- Chief, Section of Palliative Care and Medical Ethics
- University of Pittsburgh School of Medicine
Clinicians are sometimes faced with requests to provide treatments for patients in the intensive care unit (ICU) that they judge to be ill-advised. These requests often arise due to poor communication regarding prognosis and treatment goals between the treating team and the patient and/or his or her surrogates. Sometimes, such requests arise because of value disagreements between the clinicians, the patient, and/or his or her surrogates about what the goals of care should be in light of a serious medical situation.
Issues related to requests for potentially inappropriate treatments and strictly futile interventions are reviewed here. Throughout the discussion, the term "surrogates" will include the person named by the patient to make health care decisions plus any person involved in making decisions for an incapacitated patient. Other issues related to issues that arise in the ICU, palliative care, and end of life care are discussed separately.
- Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997; 25:887.
- Curtis JR, Vincent JL. Ethics and end-of-life care for adults in the intensive care unit. Lancet 2010; 376:1347.
- Fair allocation of intensive care unit resources. American Thoracic Society. Am J Respir Crit Care Med 1997; 156:1282.
- Emanuel EJ. A communal vision of care for incompetent patients. Hastings Cent Rep 1987; 17:15.
- Rawls J. Political liberalism; expanded edition, Columbia University Press, New York, NY 2005.
- Piers RD, Azoulay E, Ricou B, et al. Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. JAMA 2011; 306:2694.
- Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med 2013; 173:1887.
- Palda VA, Bowman KW, McLean RF, Chapman MG. "Futile" care: do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses. J Crit Care 2005; 20:207.
- Prendergast TJ. Resolving conflicts surrounding end-of-life care. New Horiz 1997; 5:62.
- Garros D, Rosychuk RJ, Cox PN. Circumstances surrounding end of life in a pediatric intensive care unit. Pediatrics 2003; 112:e371.
- Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest 2003; 123:266.
- Campbell ML, Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med 2004; 32:1839.
- Norton SA, Hogan LA, Holloway RG, et al. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007; 35:1530.
- Kaufer M, Murphy P, Barker K, Mosenthal A. Family satisfaction following the death of a loved one in an inner city MICU. Am J Hosp Palliat Care 2008; 25:318.
- Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003; 290:1166.
- Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med 2008; 36:953.
- Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 2005; 171:987.
- Bosslet GT, Pope TM, Rubenfeld GD, et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med 2015; 191:1318.
- Kon AA, Shepard EK, Sederstrom NO, et al. Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee. Crit Care Med 2016; 44:1769.
- Luce JM. A history of resolving conflicts over end-of-life care in intensive care units in the United States. Crit Care Med 2010; 38:1623.
- Medical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs. JAMA 1999; 281:937.
- Burns JP, Truog RD. Futility: a concept in evolution. Chest 2007; 132:1987.
- Spielman B. Collective decisions about medical futility. J Law Med Ethics 1994; 22:152.
- Sibbald RW, Chidwick P. Best interests at end of life: a review of decisions made by the Consent and Capacity Board of Ontario. J Crit Care 2010; 25:171.e1.
- Fine RL, Mayo TW. Resolution of futility by due process: early experience with the Texas Advance Directives Act. Ann Intern Med 2003; 138:743.
- Truog RD. Counterpoint: The Texas advance directives act is ethically flawed: medical futility disputes must be resolved by a fair process. Chest 2009; 136:968.
- American Medical Association Council on Ethical and Judicial Affairs. Opinion 2.20 - withholding or withdrawing life-sustaining medical treatment, 1996. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion220.page (Accessed on April 20, 2011).
- Lewis-Newby M, Wicclair M, Pope T, et al. An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med 2015; 191:219.
- PREVENTION OF CONFLICTS
- CONFLICT RESOLUTION
- Responding to requests for potentially inappropriate interventions
- Six-step process to conflict resolution
- TIME PRESSURED DECISIONS
- Responding to requests for physiologically futile interventions
- CONSCIENTIOUS OBJECTION AND REQUESTS FOR POTENTIALLY INAPPROPRIATE TREATMENT
- Do-not-escalate-treatment orders
- SUMMARY AND RECOMMENDATIONS