Conflict resolution at the end of life

Is shared decision-making to blame for the provision of ethically inappropriate treatment? Results of a multi-site study exploring physician understanding of the "shared" model of decision making

Support for the concept of respect for first-person informed consent and patient autonomy, including the negative right of patients to refuse unwanted interventions has grown, but does not generally include a positive right of patients to receive whatever treatment they request or demand without constraint. Despite this, health-care providers in both Canada and the United States are guilty of providing, in their own opinions, futile or probably futile treatments at the request of patients or their substitute decision-makers. The purpose of this study was to examine whether physicians' understanding of the shared model of medical decision-making - shared decision-making, (SDM) - may be among the reasons why some patients receive treatment understood as ethically inappropriate, including those deemed futile, treatments that are not medically indicated, or those that are not in the patient's best interests to receive. A secondary question asked to study participants was whether they believed their professional college allowed, or further, required them to use shared decision-making in their practice. The initial hypothesis of the researcher in this study was that SDM is not well understood by physicians, and that this lack of understanding, combined with other factors to be discussed in the full text, may result in patients receiving ethically-inappropriate treatment. Results suggest support for this hypothesis, and that SDM should be more closely examined if it is to be pursued as a method of decision making.

Outcomes of ICU patients with and without perceptions of excessive care: a comparison between cancer and non-cancer patients

Background

Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer.

Methods

This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer.

Results

Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60–1.72 and HR 0.87, 95% CI 0.49–1.54) and TLDs (HR 0.81, 95% CI 0.33–1.99 and HR 0.70, 95% CI 0.27–1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58–3.15 and 1.66, 95% CI 1.28–2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups.

Conclusions

The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00895-5.

Treatment Limitation Decisions in Critically Ill Patients With a Malignancy on the Intensive Care Unit

Background:

Treatment limitation decisions (TLDs) on the ICU can be challenging, especially in patients with a malignancy. Up-to-date literature regarding TLDs in critically ill patients with a malignancy admitted to the ICU is scarce. The aim was to compare the incidence of written TLDs between patients with an active malignancy, patients with a malignancy in their medical history (complete remission, CR) and patients without a malignancy admitted unplanned to the ICU.

Methods:

We conducted a retrospective cohort study in a large university hospital in the Netherlands. We identified all unplanned admissions to the ICU in 2017 and categorized the patients in 3 groups: patients with an active malignancy (study population), with CR and without a malignancy. A TLD was defined as a written instruction not to perform life-saving treatments, such as CPR in case of cardiac arrest. A multivariate binary logistic regression analysis was used to identify whether having a malignancy was associated with TLDs.

Results:

Of the 1046 unplanned admissions, 125 patients (12%) had an active malignancy and 76 (7.3%) patients had CR. The incidence of written TLDs in these subgroups were 37 (29.6%) and 20 (26.3%). Age (OR 1.03; 95% CI 1.01 -1.04), SOFA score at ICU admission (OR 1.11; 95% CI 1.05 -1.18) and having an active malignancy (OR 1.75; 95% CI 1.04-2.96) compared to no malignancy were independently associated with written TLDs. SOFA scores on the day of the TLD were not significantly different in patients with and without a malignancy.

Conclusions:

This study shows that the presence of an underlying malignancy is independently associated with written TLDs during ICU stay. Patients with CR were not at risk of more written TLDs. Whether this higher incidence of TLDs in patients with a malignancy is justified, is at least questionable and should be evaluated in future research.

Swedish intensivists' experiences and attitudes regarding end-of-life decisions

BACKGROUND

To make end-of-life (EOL) decisions is a complex and challenging task for intensive care physicians and a substantial variability in this process has been previously reported. However, a deeper understanding of intensivists' experiences and attitudes regarding the decision-making process is still, to a large extent, lacking. The primary aim of this study was to address Swedish intensivists' experiences, beliefs and attitudes regarding decision-making pertaining to EOL decisions. Second, we aimed to identify underlying factors that may contribute to variability in the decision-making process.

METHOD

This is a descriptive, qualitative study. Semi-structured interviews with nineteen intensivists from five different Swedish hospitals, with different ICU levels, were performed from 1 February 2017 to 31 May 2017.

RESULTS

Intensivists strive to make end-of-life decisions that are well-grounded, based on sufficient information. Consensus with the patient, family and other physicians is important. Concurrently, decisions that are made with scarce information or uncertain medical prognosis, decisions made during on-call hours and without support from senior consultants cause concern for many intensivists. Underlying factors that contribute to the variability in decision-making are lack of continuity among senior intensivists, lack of needed support during on-call hours and disagreements with physicians from other specialties. There is also an individual variability primarily depending on the intensivist's personality.

CONCLUSION

Swedish intensivists' wish to make end-of-life decisions based on sufficient information, medically certain prognosis and consensus with the patient, family, staff and other physicians. Swedish intensivists' experience a variability in end-of-life decisions, which is generally accepted and not questioned.

Survey highlights the need for specific interventions to reduce frequent conflicts between healthcare professionals providing paediatric end-of-life care

AIMS

This study explored how paediatric healthcare professionals experienced and coped with end-of-life conflicts and identified how to improve coping strategies.

METHODS

A questionnaire was distributed to all 2300 professionals at a paediatric university hospital, covering the frequency of end-of-life conflicts, participants, contributing factors, resolution strategies, outcomes and the usefulness of specific institutional coping strategies.

RESULTS

Of the 946 professionals (41%) who responded, 466 had witnessed or participated in paediatric end-of-life discussions: 73% said these had led to conflict, more frequently between professionals (58%) than between professionals and parents (33%). Frequent factors included professionals' rotations, unprepared parents, emotional load, unrealistic parental expectations, differences in values and beliefs, parents' fear of hastening death, precipitated situations and uncertain prognosis. Discussions with patients and parents and between professionals were the most frequently used coping strategies. Conflicts were frequently resolved by the time of death. Professionals mainly supported designating one principal physician and nurse for each patient, two-step interdisciplinary meetings - between professionals then with parents - postdeath ethics meetings, bereavement follow-up protocols and early consultations with paediatric palliative care and clinical ethics services.

CONCLUSION

End-of-life conflicts were frequent and predominantly occurred between healthcare professionals. Specific interventions could target most of the contributing factors.

Impact of Palliative Care Consultations on Resource Utilization in the Final 48 to 72 Hours of Life at an Acute Care Hospital in Ontario, Canada

A wealth of literature and economic analyses has shown that palliative care is associated with significant cost reductions compared to nonpalliative care. However, no one has assessed the impact of an inpatient palliative care consultation service on costs at the very end of life (48 to 72 hours before death). This retrospective cohort review of 100 inpatients at a large hospital in Ontario examines the effect of palliative care consultations on seven independent cost categories during this period: medical-imaging costs, physician costs, laboratory costs, pharmaceutical costs, other health professional costs, food services costs, and unit costs. Our study shows that patients who receive palliative care consultations are associated with significantly lower costs in the final 48 to 72 hours of life than their nonpalliative counterparts. Another significant finding was that the degree of cost reduction at the very end of life appears to be relative to how soon after the patient's admission the palliative care consultation was initiated.

[Limitations on Therapeutic Efforts: Much More than not Doing]

The term LTE (Limitations on Therapeutic Efforts) refers to the withholding or withdrawing of medical treatment to a patient (either with or without capacity to decide) who does not clinically benefit from it. Although some countries already have legislation and official documents to formalize it, there are several reasons limiting the dissemination and acceptance of this proposal. One is the fact that physicians and health institutions consider this issue as the sole responsibility of patients; another reason is that physicians and the community in general believe the discussion refers just to elderly and terminal patients. It is necessary an academic approach on LTE from both, physicians and the community in general, to promote a sound ethical reflection so as to assist patients and their relatives in the hard task of becoming autonomous to decide and plan their futures.

Maintaining empathy in medical school: it is possible

BACKGROUND

Empathy is an indispensable skill in medicine and is an integral part of 'professionalism'. Yet, there is still increasing concern among medical educators and medical professionals regarding the decline in medical students' empathy during medical education.

AIMS

This article aims at comparing the levels of empathy in medical school students across the different years of undergraduate medical education. It also aims at examining differences in empathy in relation to gender, year of study, cultural and religious backgrounds, previous tertiary education and certain programmes within the curriculum.

METHOD

The Jefferson Scale of Physician Empathy, Student version (JSPE-S) was employed to measure empathy levels in medical students (years one to five) in a cross-sectional study. Attached to the scale was a survey containing questions on demographics, stage of medical education, previous education, and level of completion of particular programmes that aim at promoting personal and professional development (PPD).

RESULTS

Four hundred and four students participated in the study. The scores of the JSPE-S ranged from 34 to 135 with a mean score of 109.07 ± 14.937. Female medical students had significantly higher empathy scores than male medical students (111 vs. 106, p < 0.001) across all five years of the medical course. There was no significant difference in the total empathy scores in relation to year of medical education. Yet, the highest means were scored by year five students who had completed personal and professional development courses.

CONCLUSIONS

Our findings suggest that there is a gender difference in the levels of empathy, favouring female medical students. They also suggest that, despite prior evidence of a decline, empathy may be preserved in medical school by careful student selection and/or personal and professional development courses.

Integrating palliative care in the intensive care unit

The admission of cancer patients into intensive care units (ICUs) is on the rise. These patients are at high risk for physical and psychosocial suffering. Patients and their families often face difficult end-of-life decisions that highlight the importance of effective and empathetic communication. Palliative care teams are uniquely equipped to help care for cancer patients who are admitted to ICUs. When utilized in the ICU, palliative care has the potential to improve a patient's symptoms, enhance the communication between care teams and families, and improve family-centered decision making. Within the context of this article, we will discuss how palliative care can be integrated into the care of ICU patients and how to enhance family-centered communication; we will also highlight the care of ICU patients at the end of life.

Conflicts in the ICU: perspectives of administrators and clinicians

PURPOSE

The purpose of this study is to understand conflicts in the ICU setting as experienced by clinicians and administrators and explore methods currently used to resolve such conflicts when there may be discordance between clinicians and families, caregivers or administration.

METHODS

Qualitative case study methodology using semi-structured interviews was used. The sample included community and academic health science centres in 16 hospitals from across the province of Ontario, Canada. A total of 42 participants including hospital administrators and ICU clinicians were interviewed. Participants were sampled purposively to ensure representation.

RESULTS

The most common source of conflict in the ICU is a result of disagreement about the goals of treatment. Such conflicts arise between the ICU and referring teams (inter-team), among members of the ICU team (intra-team), and between the ICU team and patients' family/substitute decision-maker (SDM). Inter- and intra-team conflicts often contribute to conflicts between the ICU team and families. Various themes were identified as contributing factors that may influence conflict resolution practices as well as the various consequences and challenges of conflict situations. Limitations of current conflict resolution policies were revealed as well as suggested strategies to improve practice.

CONCLUSIONS

There is considerable variability in dealing with conflicts in the ICU. Greater attention is needed at a systems level to support a culture aimed at prevention and resolution of conflicts to avoid increased sources of anxiety, stress and burnout.

Conflicts about end-of-life decisions in NICUs in the Netherlands

OBJECTIVE

To determine the frequency and background of conflicts about neonatal end-of-life (EoL) decisions.

METHODS

We reviewed the medical files of 359 newborns who had died during 1 year in the 10 Dutch NICUs and identified 150 deaths that were preceded by an EoL decision on the basis of the child's poor prognosis. The attending neonatologists of 147 of the 150 newborns were interviewed to obtain details about the decision-making process.

RESULTS

EoL decisions about infants with a poor prognosis were initiated mainly by the physician, who subsequently involved the parents. Conflicts between parents and the medical team occurred in 18 of 147 cases and were mostly about the child's poor neurologic prognosis. Conflicts within the team occurred in 6 of 147 cases and concerned the uncertainty of the prognosis. In the event of conflict, the EoL decision was postponed. Consensus was reached by calling additional meetings, performing additional diagnostic tests, or obtaining a second opinion. The chief causes of conflict encountered by the physicians were religious convictions that forbade withdrawal of life-sustaining treatment and poor communication between the parents and the team.

CONCLUSIONS

The parents were involved in all EoL decision-making processes, and consensus was ultimately reached in all cases. Conflicts within the team occurred in 4% of the cases and between the team and the parents in 12% of the cases. The conflicts were resolved by postponing the EoL decision until consensus was achieved.

Lack of concordance between physician and patient: reports on end-of-life care discussions

OBJECTIVE

To study the effectiveness of patient physician communications regarding health care choices at the end of life. We studied communications occurring between physicians and their patients who had either terminal cancer or congestive heart failure, with less than 6 months to live.

METHODS

This pilot study used in-person interviews with 22 physicians and 71 of their (matched) patients. Subjects provided paired responses to questions regarding their conversations related to end-of-life care, including resources, attitudes, and preferences. We calculated the concordance of patient and physician reports about these discussions. We examined the physicians' and the patients' agreement on the patient's diagnosis, and on whether a variety of care options were discussed. We then measured whether physicians' were aware of their patients' preferences for pain management and for place of death. Finally, we measured physicians' knowledge of whether religious/spiritual concerns or financial concerns had affected their patients' decisions regarding end-of-life care. Both bivariate and multivariate models were used.

RESULTS

As a whole, the concordance scores were poor; however, concordance varied across domains of issues discussed. Patients with less education had significantly lower concordance scores.

DISCUSSION

We have identified domains in which the physicians and patients may be least effective in discussing end-of-life care options. Findings may help in designing interventions to improve communication, especially for patients with less education.

Intensive care unit cultures and end-of-life decision making

PURPOSE

Prior researchers studying end-of-life decision making (EOLDM) in intensive care units (ICUs) often have collected data retrospectively and aggregated data across units. There has been little research, however, about how cultures differ among ICUs. This research was designed to study limitation of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to EOLDM.

MATERIALS AND METHODS

Ethnographic field work took place in 4 adult ICUs in a tertiary care hospital. Participants were health care providers (eg, physicians, nurses, and social workers), patients, and their family members. Participant observation and interviews took place 5 days a week for 7 months in each unit.

RESULTS

The ICUs were not monolithic. There were similarities, but important differences in EOLDM were identified in formal and informal rules, meaning and uses of technology, physician roles and relationships, processes such as unit rounds, and timing of initiation of EOLDM.

CONCLUSIONS

As interventions to improve EOLDM are developed, it will be important to understand how they may interact with unit cultures. Attempting to develop one intervention to be used in all ICUs is unlikely to be successful.

Physician perspectives on end-of-life care: factors of race, specialty, and geography

OBJECTIVES

To describe physicians' end-of-life practices, perceptions regarding end-of-life care and characterize differences based upon physician specialty and demographic characteristics. To illuminate physicians' perceptions about differences among their African-American and Caucasian patients' preferences for end-of-life care.

DESIGN AND METHODS

Twenty-four African-American and 16 Caucasian physicians (N=40) participated in an in-person interview including 23 primary care physicians, 7 cardiologists, and 10 oncologists. Twenty-four practices were in urban areas and 16 were in rural counties.

RESULTS

Physicians perceived racial differences in preferences for end-of-life care between their Caucasian and African-American patients. Whereas oncologists and primary care physicians overwhelmingly reported having working relationships with hospice, only 57% of cardiologists reported having those contacts. African-American physicians were more likely than Caucasian physicians to perceive racial differences in their patients preferences for pain medication.

SIGNIFICANCE OF RESULTS

Demographic factors such as race of physician and patient may impact the provider's perspective on end-of-life care including processes of care and communication with patients.

A critical discourse analysis of provision of end-of-life care in key UK critical care documents

This article highlights certain practical and professional difficulties in providing end-of-life (EOL) care for patients in critical care units and explores discourses arising from guidelines for critical care services.

BACKGROUND

A significant number of patients die in critical care after decisions to withdraw or withhold treatment. Guidelines for provision of critical care suggest, wherever possible, moving patients out of critical care at the EOL. This may not necessarily be conducive to a 'good death' for patients or their loved ones. There is a moral responsibility for both nurses and doctors to ensure that decision-making around EOL issues is sensitively implemented, that decisions about care includes families, patients when able, nurses and doctors, and that good EOL care is provided.

METHODS

A critical discourse analysis (CDA) of four key UK critical care documents published since 1996.

FINDINGS AND RECOMMENDATIONS

The key documents give little clear guidance about how to provide EOL care in critical care. Discourses include the power dynamic in critical care between professions, families and patients, and how this impacts on provision of EOL care. Difficulties encountered include dilemmas at discharge and paternalism in decision-making. The technological environment can act as a barrier to good EOL care, and critical care nurses are at risk of assuming the dominant medical model of care. Nurses, however, are in a prime position to ensure that decision-making is an inclusive process, patient needs are paramount, the practical aspects of withdrawal lead to a smooth transition in goals of care and that comfort measures are implemented.

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes

Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.

Ethics roundtable debate: child with severe brain damage and an underlying brain tumour

A young person presents with a highly malignant brain tumour with hemiparesis and limited prognosis after resection. She then suffers an iatrogenic cardiac and respiratory arrest that results in profound anoxic encephalopathy. A difference in opinion between the treatment team and the parent is based on a question of futile therapy. Opinions from five intensivists from around the world explore the differences in ethical and legal issues. A Physician-ethicist comments on the various approaches.

Improving care for patients dying in the intensive care unit

It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. There is ample evidence that there is room to improve the care of patients who are near death in the ICU. Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.

Controversial issues in critical care for the elderly: a perspective from Canada

Age alone does not at all preclude the possibility of warranted, effective, and successful intensive care. From a medical perspective, the key issue is the reversibility or otherwise of an acute illness and where this illness sits in the trajectory of that individual's life and possible death. It makes no more sense to admit a 19-year-old let alone a 91-year-old to an intensive care unit if intensive care cannot provide what is needed. Of paramount importance in our consideration of critical care for the elderly is a determination and an understanding of the many needs--medical, emotional, social, spiritual, psychologic--that elderly people have. By exploring them with compassion and sensitivity, we can establish whether the goals of care include critical care and the associated technology, or whether alternative and more conservative approaches more closely reflect the values and preferences of an increasingly elderly population.

Legal and ethical issues in end-of-life care

Advances in medical technology during the past 3 decades altered the scenarios of our dying. It is now possible to prolong life, with the frightening reality that we also can extend death. This paper examines challenges to dying well in America, defines key end-of-life dilemmas faced by critical care nurses, and examines legal and ethical issues related to dying persons' care. These issues include patients' decision-making capacity and right to refuse treatment; withholding and withdrawing life-sustaining treatment, including nutrition and hydration; "no code" decisions; medical futility; and assisted suicide. Implications for critical care practice, education, research and public policy are identified.

Obstacles to palliation and end-of-life care in a long-term care facility

PURPOSE

This exploratory study used a set of four obstacle constructs derived from both the existing literature and our earlier work to describe the diverse end-of-life scenarios observed for a group of residents in a long-term care facility.

DESIGN AND METHODS

Data from a retrospective chart review and both quantitative and qualitative methods of data collection and analysis were used to examine in-depth the end-of-life experiences of all nursing home residents (N = 41) who died on the nursing care unit of a large continuing care retirement community during an 18-month period.

RESULTS

A hierarchy of obstacles to palliation and end-of-life care seems to exist in long-term care settings that begins with the lack of recognition that restorative, rehabilitative, or curative treatment futility has commenced. The next three obstacles in sequence include lack of communication among decision makers, no agreement on a course of care, and failure to implement a timely plan of care.

IMPLICATIONS

The findings highlight the importance of determining treatment futility as an initial step in the successful delivery of palliative and end-of-life care to residents in long-term care followed by the need for a deliberate and proactive series of actions and care planning processes.

Ethical issues in the critically ill patient

Ethical issues have emerged in recent years as a significant component of care in the critically ill patient. Recently, the primary emphasis has been directed to care at the end-of-life. The factor that has been identified as the most important to patients and families and the one that is accomplished the least often is successful communication with the physicians. When communication does not take place or is inadequate physicians are left to try to determine what their patient's wishes would have been regarding end-of-life decisions. This leads to tremendous potential for conflict between the physician and the family, as the patients are often incapable of participating in any discussion regarding end-of-life care. Advance planning on the part of the patient in terms of making their wishes known and education of the health care professionals is essential in promoting effective communication, thereby avoiding conflict in these difficult end-of-life decisions.