The standard of care and conflicts at the end of life in critical care: lessons from medical-legal crossroads and the role of a quasi-judicial tribunal in decision-making

What is appropriate care? A qualitative study into the perceptions of healthcare professionals in Flemish university hospital intensive care units

Aim

This study examines when healthcare professionals consider intensive care as appropriate care.

Background

Despite attempts to conceptualize appropriate care in prior research, there is a lack of insight into its meaning and implementation in practice. This is an important issue because healthcare professionals as well as patients and relatives report inappropriate care in the intensive care unit (ICU) on a regular basis.

Methods

A qualitative study was designed, based on principles of grounded theory. Seventeen semi-structured interviews were conducted with nurses, doctors and doctors in training from three Flemish university hospitals. Analyses followed the Quagol method; insights were gained by means of the constant comparative method.

Results

Healthcare professionals described appropriate care as socially sustainable care, high-quality care, patient-oriented care, dignified care and meaningful care. They considered it important that care is not only proportional to the expected survival and quality of life of the patient and in line with the patient's or relatives' wishes, but also that the pursuit of the care goals is proportional to the patient's suffering.Although healthcare professionals indicated the same elements of appropriate care, they were defined and interpreted in individual and therefore different ways. This diversity lies at the basis of fields of tension and frustrations among healthcare professionals.

Conclusion

Appropriate care is defined and interpreted in individual and therefore different ways. In order to decide which type of care is appropriate for a specific patient, a process of open and constructive communication in a team is recommended.

The perils of medico-legal advocacy in ICU conflicts at the end of life: A qualitative study of what happens when advocacy and best interests collide

An unexplored aspect of conflicts and conflict resolution in the ICU at EOL is the role of advocacy in both medicine and law.

GOAL

Qualitative study to explore perspectives of SDM/patient lawyers on issues of advocacy at EOL to better understand conflicts and resolution processes.

METHODS

Purposive sampling with criterion and snowball techniques were used to recruit 11 experienced lawyers for semi-structured interviews. Interviews explored respondents' beliefs, views, and experiences with conflicts; were audio-recorded, coded inductively and iteratively following interpretive analysis. Recurring themes were identified using NVivo Qualitative Software.

RESULTS

We interviewed 11 participants and achieved conceptual saturation. Participants identified insufficient advocacy and overaggressive advocacy as major contributors to the initiation of ICU conflicts and the inhibition of resolution processes before and after the legal system is engaged. These breakdowns in advocacy contribute to challenges when conflicts arise, leading to prolongation of conflict-resolution processes and to outcomes that sometimes reflect the goals of legal advocacy rather than patient-centred goals.

CONCLUSION

This study explores legal perspective of conflict at EOL and how these perspectives can be used to inform the development of better approaches to conflict resolution.

Reason-Giving and Medical Futility: Contrasting Legal and Social Discourse in the United States With the United Kingdom and Ontario, Canada

Disputes regarding life-prolonging treatments are stressful for all parties involved. These disagreements are appropriately almost always resolved with intensive communication and negotiation. Those rare cases that are not require a resolution process that ensures fairness and due process. We describe three recent cases from different countries (the United States, United Kingdom, and Ontario, Canada) to qualitatively contrast the legal responses to intractable, policy-level disputes regarding end-of-life care in each of these countries. In so doing, we define the continuum of clinical and social utility among different types of dispute resolution processes and emphasize the importance of public reason-giving in the societal discussion regarding policy-level solutions to end-of-life treatment disputes. We argue that precedential, publicly available, written rulings for these decisions most effectively help to move the social debate forward in a way that is beneficial to clinicians, patients, and citizens. This analysis highlights the lack of such rulings within the United States.

"Must do CPR??": strategies to cope with the new College of Physicians and Surgeons of Ontario policy on end-of-life care

The College of Physicians and Surgeons of Ontario recently released a new policy, Planning for and Providing Quality End-of-Life Care. The revised policy is more accurate in its consideration of the legal framework in which physicians practice and more reflective of ethical issues that arise in end-of-life (EOL) care. It also recognizes valid instances for not offering cardiopulmonary resuscitation (CPR). Nevertheless, the policy poses a significant ethical and legal dilemma-i.e., if disputes over EOL care arise, then physicians must provide CPR even when resuscitation would fall outside this medical standard of care. While the policy applies in Ontario, it is likely to influence other physician colleges across Canada as they review their standards of practice. This paper explores the rationale for the mandated CPR, clarifies the policy's impact on the medical standard of care, and discusses strategies to improve EOL care within the policy. These strategies include understanding the help-hurt line, changing the language used when discussing cardiac arrest, clarifying care plans during the perioperative period, engaging the intensive care unit team early in goals-of-care discussions, mentoring hospital staff to improve skills in goals-of-care discussions, avoiding use of the "slow code", and continuing to advocate for quality EOL care and a more responsive legal adjudication process.

The future of decision-making in critical care after Cuthbertson v. Rasouli

PURPOSE

The Supreme Court of Canada (SCC) ruling on Cuthbertson v. Rasouli has implications for all acute healthcare providers. This well-publicized case involved a disagreement between healthcare providers and a patient's family regarding the principles surrounding withdrawal of life support, which the physicians involved considered no longer of medical benefit and outside the standard of care, and whether consent was required for such withdrawals. Our objective in writing this article is to clarify the implications of this ruling on the care of critically ill patients.

SOURCE

SCC ruling Cuthbertson v. Rasouli.

PRINCIPAL FINDINGS

The SCC ruled that consent must be obtained for all treatments that serve a "health-related purpose", including withdrawal of such treatments. The SCC did not fully consider what the standard of care should be. Health-related purpose is not sufficient in and of itself to mandate treatment, and clinicians must still ensure that their patients or decision-makers are aware of the possible medical benefits, risks, and expected outcomes of treatments. The provision of treatments that have no potential to provide medical benefit and carry only risks would still fall outside the standard of care. Nevertheless, due to their health-related purpose, physicians must seek consent for the discontinuation of these treatments.

CONCLUSION

The SCC ruled that due to the legal definition of "health-related purpose", which is distinct from medical benefit, consent is required to withdraw life-support and outlined the steps to be taken should conflict arise. The SCC decision did not directly address the role of medical standard of care in these situations. In order to ensure optimal decision-making and communication with patients and their families, it is critical for healthcare providers to have a clear understanding of the implications of this legal ruling on medical practice.