“A physician has a responsibility to present surrogates with the plan of care he or she believes to be in the best application of a patient’s authentic values and interests to a specific clinical situation,” Paul Hutchison, MD, writes in an editorial.
Taking the opposite side is Robert Veatch, PhD, of Georgetown University’s Kennedy Institute of Ethics. In a counterpoint editorial, Dr. Veatch writes physicians “have no basis for recommending treatment goals and, even if they did, they would tend to distort the decision-maker’s perspective.”
About 20 percent of Americans spend time in an intensive care unit around the time of their death, and most deaths follow a decision to limit life-sustaining therapies.Family members or other surrogate decision makers often have no experience in making end-of-life decisions for another person, and they struggle in this role. Making a decision without a recommendation may be overwhelming, Dr. Hutchison writes.
“When the patient’s prognosis is uncertain and the treatments are potentially burdensome, surrogates often look to the physician for assistance with the treatment-limitation decisions.”
After asking the surrogate about the patient’s values, the physician is equipped to offer a recommendation, provided the recommendation reflects the patent’s known values and not the physician’s personal, political, or spiritual beliefs; acknowledges the uncertainty of the prognosis; and is subject to further consideration and discussion with the surrogate. “The recommended plan is never the final word without the surrogate’s assent.”
Dr. Hutchison explores the physician’s role in two common scenarios:The surrogate asks the physician for a recommendation. Such a request “is an expression of his trust in the physician who has a reciprocal duty to provide guidance and support,” Dr. Hutchison writes. “Failure to accept this role amounts to abandonment and requires the surrogate to bear the entire burden of the decision.”
The surrogate requests aggressive therapies for a dying patient. Dr. Hutchison explains that treatments should be pursued only if they can provide benefit to the patient. “While physicians should not be individual arbiters of resource allocation at the bedside, medical resources are not infinite, and most would agree that they need to be used responsibly,” Dr. Hutchison writes.
Dr. Hutchison notes we do not allow permit physicians to make end-of-life decisions without exploring a surrogate’s preferences for treatments. Similarly, it would be odd for family members, who have no medical background or training, to make decisions without a physician’s input. “No matter what the content of the recommendation, however, it must always be offered with humility and with openness to contrasting perspectives,” Dr. Hutchison writes. “After all, the physician and surrogate are on the same team and with the same ultimate goal: respect for the interests and dignity of the critically ill patient.”
Dr. Hutchison is a specialist in pulmonary and critical care medicine. He is an assistant professor in the Department of Medicine of Loyola University Chicago Stritch School of Medicine.
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