What in the heck were these rocket scientists thinking

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Hello Everyone,

Here's a study which covers this.

(Decisions to limit life-sustaining treatment for critically ill patients who

lack both decision-making capacity and surrogate decision-makers*

Douglas B. White @ MD; J. Randall Curtis, MD, MPH; Bernard Lo, MD; John M. Luce, MD)

From the Division of Pulmonary and Critical Care Medicine, University of California, San Francisco School of Medicine (DBW), San Francisco, CA; Program in Medical

Ethics (DBW, BL) and Division of General Internal Medicine (BL), Department of Medicine, University of California,

San Francisco; Division of Pulmonary and Critical Care Medicine (JRC), Harborview Medical Center, University

of Washington, Seattle, WA; and Division of Pulmonary and Critical Care Medicine (JML), San Francisco

General Hospital, San Francisco, CA. The authors have not disclosed any potential conflicts

of interest. Supported in part by National Institutes of Health grants HL-07185 (to DBW), K24 HL 68593 (to JRC),

and MH 42459 (to BL). Dr. Lo was also supported by the Greenwall Foundation. Copyright © 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000227654.38708.C1

Objective: Many intensive care unit (ICU) physicians have withdrawn life-support from a patient who lacked decision-making

capacity and a surrogate decision-maker, yet little is known about the decision-making practices for these patients. We

sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them.

Design: Prospective, observational cohort study. Patients and Setting: Consecutive adult patients admitted to

the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004.

Measurements: Attending physicians completed a questionnaire about the decision-making process for each patient for

whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decisionmaker.

Main Results: Of the 303 patients admitted during the study period, 49 (16%; 95% confidence interval [CI], 12–21%) lacked

decision-making capacity and a surrogate during the entire ICU stay. Compared with all other ICU patients, these patients were

more likely to be male (88% vs. 69%; p .002), white (42% vs. 23%; p .028), and >65 yrs old (29% vs. 13%; p .007).

Physicians considered withholding or withdrawing treatment from 37% (18) of the 49 patients who lacked both decisionmaking

capacity and a surrogate decision-maker. For 56% (10) of these 18 patients, the opinion of another attending physician was

obtained; for 33% (6 of 18), the ICU team made the decision independently, and for 11% (2 of 18), the input of the courts or the hospital ethics committee was obtained. Overall, 27% of deaths (13 of 49) during the study period involved incapacitated patients who lacked a surrogate (95% CI, 15–41%).

Conclusions: Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and

a surrogate decision-maker. Decisions to limit life support were generally made by physicians without judicial or institutional

review. Further research and debate are needed to develop optimal decision-making strategies for these difficult cases. (Crit

Care Med 2006; 34:●●●–●●●)

KEY WORDS: surrogate decision-maker; end-of-life treatment

Many patients admitted to intensive care units (ICUs) are unable to participate in decisions about their medical care (1, 2). As a result, surrogate decision-makers are often asked to make end-of-life treatment decisions for them, using either the substituted judgment standard or the best interest standard (3). This approach promotes patient autonomy and informed decision-making, central tenets of Western bioethics (3–5). However, some decisionally incapacitated patients do not have anyone available to serve as a surrogate decision-maker (6–9). Asch and colleagues (6) documented that one third of ICU physicians have acknowledged discontinuing mechanical ventilation in such a patient. These cases raise ethical and legal questions about who should make decisions for incapacitated patients without surrogates and under what circumstances it is permissible to forego life-sustaining treatment. Most states do not have laws that address how decisions to limit life-sustaining

treatment should be made for decisionally incapacitated adults without surrogates (10). In states that do have such laws, some give physicians complete authority to limit life-sustaining treatment, whereas others require that a legal guardian be appointed by the court to make the decision (10). Guidelines from the American Medical Association recommend judicial review for such cases, and those of the American Geriatrics Society advise against routine involvement of the courts and recommend an institutional multidisciplinary review for such decisions (11, 12). It is unknown which recommendations, if any, physicians follow

when making treatment decisions for these patients. Moreover, no studies have determined how frequently incapacitated patients without surrogates are admitted to ICUs, nor have studies systematically analyzed the process by which decisions

to limit life-sustaining treatment are made for them. Therefore, we sought to determine how often decisionally incapacitated patients without surrogates are admitted to the ICU of a metropolitan hospital and *See also p. 000. how decisions to limit life-sustaining treatment are made for them.

METHODS

Study Design, Patients, and Setting. This prospective longitudinal cohort study included all adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004. The study was approved by the hospital’s institutional review board. Patients were considered to lack decisionmaking capacity if the ICU physician determined

they were unable to participate in decisions about their medical care. We used the physicians’ assessments of decisional capacity rather than performing formal cognitive testing in order to capture how decisions were made in clinical practice, although physicians’ assessments of decision-making capacity correlate highly with the results of formal cognitive testing (13). Patients were considered to lack a surrogate decision-maker if they had no family, legally appointed guardian, or health care proxy available and willing to participate in decisions about their medical care. Written advance directives were defined as documents signed by the patient delineating any aspect of their end-of-life treatment preferences. The study institution serves many of the uninsured residents of the region. Many of the patients are homeless or marginally housed. The hospital does not have an institutional policy addressing how end-of-life treatment decisions should be made for decisionally incapacitated

patients who lack a surrogate decision- maker and an advance directive. Initial Evaluation and Follow-Up. Daily, we contacted the ICU physician to determine whether a patient had been admitted in the previous 24 hrs who lacked decision-making

capacity, a surrogate decision-maker, and an advance directive. If so, we recorded the patient’s demographic and clinical characteristics (age range, gender, race/ethnicity, reason for ICU admission) from the physician. Thereafter, we contacted the ICU team on a daily basis to determine whether the patient had regained decision-making capacity or a surrogate

decision-maker had been located. Physicians were aware that the purpose of the study was to understand processes of care for patients without surrogates, but they were not aware of the specific research questions. We recorded from the ICU physicians the number of days each patient lacked both decisionmaking capacity and a surrogate decisionmaker

in the ICU and whether they survived to ICU discharge. In addition, for each patient identified, we contacted the attending ICU physician twice weekly to determine whether he or she had either written or considered writing a “do not resuscitate” (DNR) order or an order to withdraw life-sustaining treatments. If so, the attending physician completed a questionnaire about the decisionmaking process, which is described below. At the end of the study period, we used the ICU admission log and administrative records to determine the demographic characteristics and mortality rate for all other patients admitted to

the medical ICU during the study period.

Process by Which Surrogate Decision-

Makers are Located. When a decisionally incapacitated patient was admitted, the ICU social workers and clinicians regularly took several steps to determine whether a surrogate decision-maker was available. First, the team reviewed the patient’s medical record to locate contact information for anyone who may have had knowledge of the patient’s values or treatment preferences. Then the social workers made telephone calls to any noted contacts, including the patient’s primary care physician, the next of kin, or supervisors from facilities from which the patient came. If these attempts did not yield a surrogate, the police were dispatched to the patient’s listed address to attempt to locate anyone with knowledge of the

patient. If the patient’s name and address were unknown, he or she was fingerprinted and the

police attempted to identify the patient and locate relatives or friends. The process continued

until a surrogate was found or until all options were exhausted.

Questionnaire Development. The questionnaire addressed basic patient and physician demographic

characteristics and physician attitudes about making decisions for incapacitated patients. In addition, physicians were asked to

indicate what factors influenced the decision of whether life-sustaining treatment should be limited and who was involved in the decisionmaking process. The items on the questionnaire were generated from expert opinion and review of the medical and legal literature on decisionmaking for decisionally incapacitated patients without surrogates (10, 14–18). The questionnaire

is available from the authors. Pretesting. To ensure the clarity of the questionnaire, we conducted semistructured interviews

with seven attending physicians and five housestaff. All 12 had prior experience treating decisionally incapacitated patients without surrogates. After completing the questionnaire, physicians underwent cognitive interviewing with the study investigator in which they verbalized what they thought each question meant and why they selected each answer. Through this

process, the questionnaire was refined for both clarity and brevity. To assess the quality of the final instrument, three research methodologists were asked the following three questions: Are the response options easy to understand (clarity)?

Are the questions directed at important elements of the decision-making process (face validity)? Is the questionnaire likely to distinguish between different approaches to decisionmaking for these patients (utility and discriminability)? All three experts endorsed the instrument’s clarity, face validity, utility, and discriminability (19). The reliability of the questionnaire was assessed with use of hypothetical test cases administered to a group of intensivists not involved in the study. Questionnaires were completed on two occasions, 2 wks apart. Test-retest reliability was assessed with use of the kappa statistic, a measure of agreement beyond chance. The average kappa value was 0.84, and all values were above 0.70. A kappa value of 0.75

is considered excellent reliability.

Legal Considerations. Physicians may believe that they are in legal jeopardy if they forego life-sustaining treatment for a patient who cannot give informed consent and who has no legally recognized surrogate decisionmaker available. Therefore, we took several steps to protect the physicians’ and patients’ identities. The study was anonymous for both patients and physicians. We recorded only general demographic characteristics that could not be used to identify specific physicians or patients. To further protect the physicians who participated in this research from the potential for legal prosecution, all identifying information about the physicians and the institution have been removed from the article. To minimize the chance that study records would allow a direct link between individual physicians and specific treatment decisions for particular patients, no chart review was performed. We also obtained a Federal Certificate of Confidentiality from the National Institutes of Health, which permits the study investigators to refuse to turn over study records in the event of a legal inquiry (20).

Statistical Analysis. Statistical analyses were performed with STATA version 8 (Stata, College Station, TX). All tests were two-tailed. categorical data were analyzed with the chisquare test. Normally distributed interval variables were analyzed with unpaired Student’s t-tests. ICU length of stay had a severe right skew. Therefore, we used medians, interquartile

ranges, and the Mann-Whitney rank-sum test for this variable.

RESULTS

Patients. Of the 303 patients admitted

to the medical ICU during the study period,

24% lacked decision-making capacity

and a surrogate decision-maker during

the first 2 days of the ICU stay (72 of

303; 95% confidence interval [CI], 19–

29%) (Fig. 1). None of these 72 patients

had an advance directive specifying endof-

life treatment preferences. The demographic

and clinical characteristics of

these patients are described in Table 1. In

comparison with all other patients admitted

to the medical ICU during the study

period, decisionally incapacitated patients

without surrogates were more

likely to be male (88% vs. 69%; p .002),

white (42% vs. 23%; p .028), 65 yrs of

age or older (29% vs. 13%; p .007), and

admitted for respiratory failure (49% vs.

34%; p .001).

Course in the Intensive Care Unit. Of

the 72 patients who initially lacked deci-

2 Crit Care Med 2006 Vol. 34, No. 8

sion-making capacity and a surrogate decision-

maker, outcome data were available

on 71 (Fig. 1). Twenty-four percent

(17 of 71) regained decision-making capacity

before a surrogate decision-maker

could be located. For another 7% (5 of

71), a surrogate decision-maker was located

after a median of 4 days in the ICU

(range, 3–31 days). The remaining 69%

(49 of 71) did not regain decision-making

capacity, nor was a surrogate decisionmaker

located. The ICU length of stay for

these 49 patients was significantly longer

than that for patients who had decisionmaking

capacity or a surrogate decisionmaker

(median of 6 days, with interquartile

range [iQR] of 4–10 days, vs. median

of 3 days, with IQR of 2–6 days), respectively

(p .0001).

The overall ICU mortality rate during

the study period was 16% (49 of 303; 95

CI, 12–20%). There was not a statistically

significant difference in mortality rates

between decisionally incapacitated patients

without surrogates and all other

ICU patients (18% vs. 15%; p .56).

Twenty-seven percent of deaths (13 of 49)

during the study period involved incapacitated

patients who lacked a surrogate

decision-maker (95% CI, 15–41%).

Decisions to Write a DNR Order or

Withdraw Life Support. The attending

physician considered writing a DNR order

for 37% (18) of 49 patients who remained

decisionally incapacitated and without a

surrogate decision-maker during their

entire ICU stay (Table 2). The median

time in the ICU before such consideration

was 10 days (range, 3–41 days). Figure 2

delineates the decision-making and outcomes

for these 49 patients. For 13 of 18

patients, a DNR order was ultimately

written. The decision was made solely by

the attending ICU physician and his or

her team for four of the 13 patients. For

seven patients, the opinion of a second

attending physician or the patient’s primary

care physician was obtained before

a DNR order was written. The hospital

ethics committee was involved in making

decisions for one patient, and for another

there was an institutional review of the

case and the court was petitioned to appoint

a legal guardian.

Physicians cited a number of reasons

why they considered writing a DNR order

or withdrawing treatment (Table 3). Poor

prognosis for survival to hospital discharge

was the most commonly cited reason

for considering a DNR order (12 of

18). For 11 of 18 patients, judgments

about future quality of life were factors in

the decision-making process. For nine of

18 patients, ICU physicians based their

decision, at least in part, on input from

the primary care physicians indicating

that the patients may not have wanted

further treatment. Concerns about inappropriate

use of scarce resources influenced

the decision for three patients.

When a DNR order was considered but

not written (n 5), all physicians reported

that writing a DNR order was not

medically appropriate. For two of these

five patients, physicians also reported legal

concerns about writing a DNR order.

Physicians considered withdrawing

life support from 15 of the 18 patients for

whom they considered writing a DNR order.

Treatment was ultimately withdrawn

for eight of these patients. The breakdown

of who was involved in the decision

to withdraw treatment was similar to that

for writing a DNR order (data not shown).

Physicians cited poor prognosis for shortterm

survival as a reason for the decision

in all eight withdrawal cases (Table 3). All

eight patients died in the ICU. For the

seven other patients, physicians considered

writing an order to withdraw life

Table 1. Demographic and clinical characteristics of the 303 study patients

Characteristic

No. (%) of Patients

p Value

Incapacitated, Without

Surrogate (n 72)

With Decision-Making Capacity

or a Surrogate (n 231)

Age, yrs .007

40 13 (18) 60 (26)

40–64 38 (53) 140 (61)

64 21 (29) 31 (13)

Male 63 (88) 159 (69) .002

Race/ethnicitya .028

White 30 (42) 52 (23)

Black 21 (29) 78 (34)

Asian 10 (14) 31 (13)

Hispanic 8 (11) 50 (22)

Other 3 (4) 12 (5)

Primary organ dysfunction .001

Respiratory 35 (49) 79 (34)

Cardiovascular 11 (15) 43 (19)

Neurologic 18 (25) 34 (15)

Hepatic 3 (4) 4 (2)

Gastrointestinal 2 (3) 45 (20)

Hematologic 2 (3) 1 (0)

Renal 1 (1) 8 (3)

Endocrine 0 (0) 17 (7)

aData are missing on eight subjects who had decision-making capacity or a surrogate decisionmaker.

Figure 1. Profile of patients admitted to the medical intensive care unit (MICU) during the study

period. Percentages are given, with the denominator expressed as the total number of ICU admissions

during the study period. *Data on one subject were missing.

Crit Care Med 2006 Vol. 34, No. 8 3

support but did not do so. Physicians

reported they ultimately decided it was

not medically appropriate to withdraw

life support from these seven patients,

and all but one patient survived. For

three of these seven patients, physicians

also cited legal concerns about withdrawing

treatment, and for two patients there

were disagreements among the physicians

about whether it was appropriate to

withdraw life support.

DISCUSSION

This is the first study to provide information

about the proportion of ICU patients

who lack both decision-making capacity

and a surrogate decision-maker

and to examine how end-of-life decisions

are made for them. Sixteen percent of

patients admitted to the medical ICU of

this metropolitan West Coast hospital

were not able to participate in their medical

decisions and lacked a surrogate decision-

maker. In addition, one of every

four deaths in the medical ICU occurred

in this patient population. We found wide

variation in the process by which physicians

decided whether to limit lifesustaining

treatment for these patients.

Figure 2. Flow diagram for the 49 patients who lacked both decision-making capacity and a surrogate

decision-maker during the entire intensive care unit (ICU) admission (DM, decision-maker; DNR, do

not resuscitate). *Physicians considered withdrawing treatment from two of these patients but

ultimately did not do so.

Table 2. Characteristics of the 18 patients for whom physicians considered writing a do not resuscitate (DNR) order

Age, yrs Gender Race

Primary

Organ

Dysfunction

Days in ICU

Before

Consideration

of Writing

DNR Order Outcome

Persons Involved in the Decision-Making Process

ICU

Team

PMD or

Another

Attending

MD

Ethics

Committee

Institutional

Review

Judicial

Review Other

DNR order not written

40–64 M Black Respiratory 24 Survived

64 M Black Respiratory 4 Died

40 M White Respiratory 12 Survived

64 M White Respiratory 16 Survived

40 F Hispanic Hematologic 3 Survived

DNR order written

40–64 F Black Respiratory 3 Died

40–64 M Black Respiratory 8 Survived

64 M Asian Respiratory 23 Died

64 M Black Renal 41 Survived

40–64 M White GI 18 Died

(Neighbor)

40–64 M Asian Cardiovascular 15 Died

64 M Asian Respiratory 10 Died

40–64 M Black Respiratory 7 Died

40–64 M Am.

Indian

Hepatic 4 Survived

40–64 M White Respiratory N/Aa Survived

64 M White Respiratory N/Aa Died

(Prior ICU

MD)

64 M Asian Respiratory N/Aa Died

40–64 M Hispanic Respiratory N/Aa Died

ICU, intensive care unit; PMD, primary outpatient physician.

aData are missing or not collected for these four patients.

4 Crit Care Med 2006 Vol. 34, No. 8

Some decisions were made independently

by the treating physicians, some were

made in conjunction with other physicians,

and, rarely, the hospital ethics

committee or the courts were involved.

Several prior studies and a case-series

have documented that limitation of lifesupport

occurs for decisionally incapacitated

patients who lack a surrogate (2, 7,

8, 21–23). In a survey administered to

879 physicians practicing in adult ICUs in

the United States, one third of the respondents

indicated that they had withdrawn

mechanical ventilation for at least

one decisionally incapacitated patient

without a surrogate (6). Smedira et al.

reported that 11% of decisions to limit

life-sustaining treatment involved incapacitated

patients who did not have a

family member available to serve as a

decision-maker (7). A study of similar design

performed 5 yrs later at the same

institution yielded similar findings (21).

Although these investigations identified

end-of-life decision-making for this patient

population as a common issue in

the ICU, they did not address who was

involved in these ethically challenging

decisions or what factors influenced the

ultimate choice of whether to withdraw

life-support.

The current study adds several important

pieces of knowledge to our understanding

of decision-making for this population.

First, patients without surrogates

are encountered in the ICU; one in six

patients admitted to this medical ICU remained

incapacitated and without a surrogate

during their entire ICU stay. Comparable

data from other institutions do not

exist, but it is likely that this is a common

problem in other hospitals that serve a similar

patient population. A study of decisionally

incapacitated nursing home patients in

New York state revealed that more than one

third did not have a surrogate decisionmaker

available to make decisions about

DNR orders (24).

Second, the median ICU length of stay

for incapacitated patients without surrogates

was twice that of all other ICU patients.

One possible explanation for this is

that incapacitated patients without surrogates

had more-severe illness than

other ICU patients. Although we were unable

to record APACHE II scores because

of the strict confidentiality protections

required to conduct the study, this hypothesis

is supported by the observation

that incapacitated patients without surrogates

were older and had a higher proportion

of respiratory failure than all

other ICU patients. Another possible explanation

for the longer length of stay is

that, in the absence of information about

a patient’s wishes, physicians tended to

continue treatment longer than they

would have for a similarly situated patient

who either had decision-making capacity

or a surrogate. Commentators

have raised concern that, depending on

the reimbursement structure of the individual

hospital, there may be a systematic

bias in favor of either overtreatment or

undertreatment of these patients (25).

Further research is needed to determine

the relative contribution of each of these

factors to the longer length of stay observed

in this patient population.

This study provides new information

about the factors important to physicians

when making actual end-of-life treatment

decisions for critically ill, incapacitated

patients who lack surrogate decisionmakers.

Physicians based these decisions

predominantly on the patients’ chances

to survive the hospitalization but also on

more subjective criteria, such as the patients’

anticipated quality of life, their

own perception of what was in the patients’

best interest, and concerns about

appropriate resource allocation. Prior

studies suggest that some of these criteria

may be problematic (26, 27). First, there is

evidence that physicians’ ratings of patients’

quality of life are systematically

lower than patients’ own assessments (28).

Second, physicians often project their own

treatment preferences onto their patients

(29). Many of the patients cared for in the

study ICU are homeless or marginally

housed, and these patients tend to prefer

more aggressive life-sustaining treatment

than physicians (30). These studies suggest

that physicians may not be well positioned

to independently decide when to limit

life-sustaining treatment if the decision

is based on value judgments about quality

of life.

Last, we found considerable variation

in who was involved in the decisions to

limit life-sustaining treatment when neither

the patient nor family could participate

in the decision. The ICU team often

involved other physicians, sometimes

made the decision unilaterally, and rarely

Table 3. Considerations used in deciding whether to limit life-sustaining treatment for 18 incapacitated

patients without surrogate decision-makers

Rationale Cited No. (%) of Patients

For DNR Order

DNR Order Considered

But Not Written

(n 5)

DNR Order Written

(n 13)

Total

(n 18)

Poor prognosis for hospital

survival

2 (40) 10 (77) 12 (67)

Predicted poor quality of life 2 (40) 9 (69) 11 (61)

Evidence that further

treatment may not be

consistent with patient’s

wishes

3 (60) 6 (46) 9 (50)

Treatment was not in the

patient’s best interest

1 (20) 5 (39) 6 (33)

Inappropriate use of limited

resources

2 (40) 1 (8) 3 (17)

For withdrawing life support

Withdrawal Considered

But Not Carried Out

(n 7)

Life Support

Withdrawn

(n 8)

Total

(n 15)

Poor prognosis for hospital

survival

3 (43) 8 (100) 11 (73)

Predicted poor quality of life 4 (57) 5 (63) 9 (60)

Evidence that further

treatment may not be

consistent with patient’s

wishes

2 (29) 5 (63) 7 (47)

Treatment was not in the

patient’s best interest

1 (14) 4 (50) 5 (33)

Inappropriate use of limited

resources

2 (29) 0 (0) 2 (13)

DNR, do not resuscitate.

Crit Care Med 2006 Vol. 34, No. 8 5

involved the courts or the hospital ethics

committee. The inconsistent approach to

decision-making for these patients is not

surprising, given the lack of agreement in

state laws (10) and professional society

policies on this issue (11, 12). These documents

differ significantly in the role of

the courts in end-of-life decision-making

for these patients, the amount of authority

granted to physicians, and the situations

in which it is permissible to withdraw

life support. Several commentators

and ethicists have raised concerns about

the absence of due process and the potential

for conflict of interest when physicians

assume sole decision-making responsibility

for patients (15, 25, 31, 32).

Additionally, a number of studies have

documented that physicians vary widely

in their beliefs about when it is appropriate

to limit life-sustaining treatment for

critically ill patients (33–36). These studies

suggest that, in the absence of input

from the patient or the patient’s surrogate,

reliance on physicians as decisionmakers

may result in similarly situated

patients receiving different levels of treatment.

Despite their procedural differences,

expert recommendations consistently

stress the need for a due process procedure

when making decisions to forego life

support in incapacitated patients without

surrogates, such as an internal multidisciplinary

committee or external judicial

review (10, 12, 37). Ideally, decisions

made by these committees would be patient-

centered, free from conflicts of interest,

and based upon the expertise of a

diverse group (10, 37). Additionally, the

committee must be available to make decisions

in a timely manner (25). Several

investigators have described the development

of such procedures (10, 15), but

more research is needed on their practical

implementation and effectiveness.

There are several limitations of our

study. Information about the decisionmaking

process was collected directly

from the physicians who were making the

treatment decisions. It is possible that

the physicians’ decision-making process

was influenced by the knowledge that

they were being studied. It is also possible

that, out of fear of professional scrutiny

or legal action, physicians reported a

more normative approach to decisionmaking.

We took measures to minimize

the possibility that this would occur, including

making the surveys anonymous

and obtaining a Federal Certificate of Confidentiality.

Second, because the study was

conducted at a single hospital, the results

may not be generalizable to other institutions,

particularly those with a patient population

substantially different from that of

the study hospital. Nonetheless, with increasing

numbers of disenfranchised individuals

in the United States (38), it seems

likely that this is a common problem in the

many hospitals serving these individuals.

Next, we did not record information about

the decision-making process for patients

who had decision-making capacity or a surrogate

decision-maker and therefore could

not compare end-of-life decision-making

practices between these two groups. This is

an important area for future research. Finally,

our sample size was too small to

determine whether there were significant

differences between patients for whom physicians

limited life-support and those for

whom they considered doing so but ultimately

decided to continue full treatment.

This study documents that dilemmas

are common regarding end-of-life treatment

for patients who lack both decisionmaking

capacity and a surrogate decisionmaker.

The decision-making practices for

these patients were variable but generally

involved decision-making solely by physicians.

It is unclear if this approach provides

adequate safeguards to ensure that decisions

for these patients are fair and consistent.

Further research and debate are

needed to develop optimal decision-making

procedures for these difficult cases.

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[monster_medic]

morals and ethics.........that is the question

[SSaint]

morals and ethics.........that is the question

Yes, yes it is.

That sums it up nicely.

[Ace844]

Here's an interesting article on the systemic failure of healthcare institutions which I touch on in my post.

[web:cb71c37497]http://www.liebertonline.com/doi/pdf/10.1089/bsp.2006.4.135[/web:cb71c37497]

What do you all think now?

Out Here,

ACE844

[Andrewtx]

I don't think this is analogous to a mass-casualty triage situation. The fact that some patients who are extremely unlikely to survive are given less or no care than those who have a better chance to be saved involves a passive denial of effort. These individuals are accused of an active effort to terminate the lives of their patients.

You might feel that either case is ethically sound, but they are nonetheless different and have to be treated that way -- especially in the eyes of the law.

[Ace844]

I don't think this is analogous to a mass-casualty triage situation. The fact that some patients who are extremely unlikely to survive are given less or no care than those who have a better chance to be saved involves a passive denial of effort. These individuals are accused of an active effort to terminate the lives of their patients.

You might feel that either case is ethically sound, but they are nonetheless different and have to be treated that way -- especially in the eyes of the law.

If this wasn't an MCI-Disaster situation, than what would you call it? Please explain your above statement further,

Thanks,

ACE844

[Andrewtx]

If this wasn't an MCI-Disaster situation, than what would you call it? Please explain your above statement further,

Thanks,

ACE844

The individuals are charged with second degree murder. They're accused of administering lethal doses of drugs to kill their patients. This is an active effort -- they are actively working to expedite the death of their patients.

It is not comparable to leaving one patient whose life is extraordinarily unlikely to be saved or revived in order to work on someone who has a reasonable chance of survival. They're different actions, and certainly have different legal issues at play.

[Ace844]

The individuals are charged with second degree murder. They're accused of administering lethal doses of drugs to kill their patients. This is an active effort -- they are actively working to expedite the death of their patients.

It is not comparable to leaving one patient whose life is extraordinarily unlikely to be saved or revived in order to work on someone who has a reasonable chance of survival. They're different actions, and certainly have different legal issues at play.

Did you read the entire thread? Please refrence my earlier posts where this is explained.

Thanks,

ACE844

[Andrewtx]

Did you read the entire thread? Please refrence my earlier posts where this is explained.

Thanks,

ACE844

I was responding to this

I guess what I am saying is that if they did NOTHING, or were deliberately trying to cause harm, pain, discomfort, etc... That would be one thing, but they did all they could and then did their best to be humane about it when they could do no more and were forced to make a tough call. They DESERVE OUR SUPPORT!! This is no different than when in your analogy when you work a critical 'RED TAG' patient and their illness progresses to the point where ressus, is futile and the end point will remain unchanged.

It is actually the same mindset of 'START' or rapid triage just over a longer time. You do what you can for as many patients as you can until it becomes unteneable for the group and you to continue their care at the same standard level especially with or in the case of physiologic decompensation and or non-response to this treatment. Conversely, what 'discussion' and 'charges' do you think these clinicians would have faced if they did the opposite and dedicated all available resources and care to these patients only later to have a suplly issue or have the other patients sufferr and recieve no to negligent lacking care? It was and is a no-win situation. If they had the intent to 'murder' no care would have been given, and many more patients would have been killed, and or they would have fled for their own safety as oppossed to 'sticking it out like they did.

I disagree that it is the same mindset. Clearly in an MCI certain patients are not given the same attention and level of care as if they had been the only patient. But for this to be comparable, you'd have to have someone administering lethal doses at MCIs to patients whose outcome were undoubtedly grave, rather than just moving on to those who could still be helped.

[Ace844]

I was responding to this