Guidelines for Resolving ICU Treatment Disputes

Intensive care unit (ICU)
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Care of the critically ill patient can become complicated when a clinician is asked by the patient's family to administer invasive interventions that the clinician believes will not benefit the patient. Resolving this kind of conflict and other issues concerning treatment of intensive care patients is the primary aim of a new policy statement from the American Thoracic Society.

When such conflicts arise between clinicians and patients' families, "a fair process of dispute resolution should be undertaken, in which neither individual can unilaterally impose his or her will on the other," according to Douglas White, MD, MAS, UPMC Chair for Ethics in Critical Care Medicine, and co-chair of the committee that produced these guidelines.

"Clinicians should neither simply acquiesce to treatment requests that they believe are not in a patient's best interest, nor should they unilaterally refuse to provide treatment," notes Dr. White, an associate professor in the University of Pittsburgh Department of Critical Care Medicine.

The guidelines emphasise that conflicts in the ICU can be prevented through early and intensive communication between the patient's family and the healthcare team. When conflicts cannot be resolved with ongoing dialogue, the policy statement recommends early involvement of expert consultants, such as palliative care and ethics consultants, to help find a negotiated agreement.

If a dispute remains unresolved despite thorough negotiation, the guidelines recommend a fair process of dispute resolution, involving a review of the case by a multidisciplinary ethics committee within the hospital, ongoing mediation, a second medical opinion, offering family the option to seek to transfer the patient to an alternate institution, and informing the family of their right to appeal to the courts.

The guidelines, published online in the American Journal of Respiratory and Critical Care Medicine, are supported by the Society of Critical Care Medicine, the American Association of Critical Care Nurses, the American College of Chest Physicians and the European Society of Intensive Care.

The policy statement also outlines innovative procedures for two additional situations. When families request treatment that is truly futile — ie, it simply cannot accomplish its physiologic aims — the clinician should refuse to administer the treatment and should clearly explain the rationale behind the treatment decision. Moreover, for situations in which medical urgency does not allow compliance with the longer dispute resolution process, the guidelines provide expedited steps that still ensure a fair process.

"These guidelines provide clinicians with a framework to manage treatment disputes with an emphasis on procedural fairness, frequent communication, expert consultation and timeliness," explains co-chair Gabriel T. Bosslet, MD, assistant professor of clinical medicine at the Charles Warren Fairbanks Center for Medical Ethics at Indiana University. "We hope that states will adopt laws similar to these guidelines, so that all sides in a particular dispute can have the resources they need to come to a resolution."

Source: American Thoracic Society
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Bosslet GT, White DB et al. (2015) An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. American Journal of Respiratory and Critical Care Medicine, 2015; 150515150017006 DOI: 10.1164/rccm.201505-0924ST

Published on : Wed, 20 May 2015

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healthmanagement, critically ill, intensive care, ICU, dispute resolution, decision-making Care of the critically ill patient can become complicated when a clinician is asked by the patient's family to administer invasive interventions that the clinician believes will not benefit the patient.

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