An important Policy Statement was recently published on responding to requests for potentially inappropriate treatments in the ICU, endorsed by five critical care organizations, authored by many of the leading international voices in ICU Palliative Care and ICU Medical Ethics. This policy statement represents a wonderful opportunity to engage your hospital in establishing policies and processes to manage ICU conflicts in an organized fashion, instead of relying on each ICU clinician and palliative care team to find solutions on an ad hoc case-by-case basis. Key policy recommendations:
Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultation (including palliative care).
The term “potentially inappropriate” should be used, rather than “futile,” to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should communicate and advocate for the treatment plan they believe is appropriate. Requests for potentially inappropriate treatment that remain intractable despite intensive communication and negotiation should be managed by a fair process of dispute resolution.
The term “futile” should only be used in the rare circumstance that an intervention simply cannot accomplish the intended physiologic goal. Clinicians should not provide futile interventions and should carefully explain the rationale for the refusal.
The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used.
The policy statement includes suggested systems change and clinician education steps to improve communication along with a suggested due process for managing intractable conflicts.
PCNOW urges all members to help move these policy guidelines from theory to practice. You should look upon the specific recommendations as starting points for discussion and adapt them to meet the needs of your setting. Here are some concrete steps that PCNOW users can take:
Provide a copy of the article to your Chief Medical, Nursing and Quality Officer, Ethics Committee chair, ICU medical and nursing directors and director of Risk Management; do not send by mail, deliver face to face.
Ask to have this topic as an agenda item for the hospital ethics, critical care, and quality committees.
Offer to serve on an implementation committee to develop the specific policies, system changes and education efforts recommended in the article.
Offer to help develop a communication skills training program for ICU staff and other clinicians.
Advocate for the ICU to adopt the suggested system-change recommendations.
Please tell us how you are doing, use the PCNOW Forum to report your progress.