A framework for resolving disagreement during end of life care in the critical care unit.

BACKGROUND End-of-life decisions regarding the administration, withdrawal or withholding of life-sustaining therapy in the critical care setting can be challenging. Disagreements between health care providers and family members occur, especially when families believe strongly in preserving life, and physicians are resistant to providing medically "futile" care. Such disagreements can cause tension and moral distress among families and clinicians. PURPOSE To outline the roles and responsibilities of physicians, substitute decision makers, and the judicial system when decisions must be made on behalf of incapable persons, and to provide a framework for conflict resolution during end-of-life decision-making for physicians practicing in Canada. SOURCE We used a case-based example to illustrate our objectives. We employed a comprehensive approach to understanding end-of-life decision making that included: 1) a search for relevant literature; 2) a review of provincial college policies; 3) a review of provincial legislation on consent; 4) a consultation with two bioethicists and 5) a consultation with two legal experts in health law. PRINCIPAL FINDINGS In Canada, laws about substitute decision-making for health care are primarily provincial or territorial. Thus, laws and policies from professional regulatory bodies on end-of-life care vary across the country. We tabulated the provincial college policies on end-of-life care and the provincial legislation on consent and advance directives, and constructed a 10-step approach to conflict resolution. CONCLUSION Knowledge of underlying ethical principles, understanding of professional duties, and adoption of a process for mediation and conflict resolution are essential to ensuring that physicians and institutions act responsibly in maintaining a patients' best interests in the context of family-centred care.

[1]  B. Carter,et al.  Addressing end of life care issues in a tertiary treatment centre: lessons learned from surveying parents’ experiences , 2010, Journal of child health care : for professionals working with children in the hospital and community.

[2]  R. Sibbald,et al.  Best interests at end of life: a review of decisions made by the Consent and Capacity Board of Ontario. , 2010, Journal of critical care.

[3]  C. Sprung,et al.  Prevalence and factors of intensive care unit conflicts: the conflicus study. , 2009, American journal of respiratory and critical care medicine.

[4]  Amani A Babgi Legal Issues in End-of-life Care: Perspectives from Saudi Arabia and United States , 2009, The American journal of hospice & palliative care.

[5]  C. Schorr Using the medical record to evaluate the quality of end-of-life care in the intensive care unit , 2009 .

[6]  Joaquín Zuckerberg End-of-life decisions: a view from Ontario and beyond. , 2009, European journal of health law.

[7]  J. Luce,et al.  A history of ethics and law in the intensive care unit. , 2009, Critical care clinics.

[8]  R. Truog,et al.  Intercontinental differences in end-of-life attitudes in the pediatric intensive care unit: Results of a worldwide survey* , 2008, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[9]  D. White,et al.  Practical guidance for evidence-based ICU family conferences. , 2008, Chest.

[10]  Curtis E. Haas,et al.  Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine , 2008, Critical care medicine.

[11]  D. Inwald The best interests test at the end of life on PICU: a plea for a family centred approach , 2007, Archives of Disease in Childhood.

[12]  Robert G. Holloway,et al.  Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients , 2007, Critical care medicine.

[13]  C. Sprung,et al.  The importance of religious affiliation and culture on end-of-life decisions in European intensive care units , 2007, Intensive Care Medicine.

[14]  B. Souweine,et al.  A communication strategy and brochure for relatives of patients dying in the ICU. , 2007, The New England journal of medicine.

[15]  Amy P. Abernethy,et al.  Conflict associated with decisions to limit life-sustaining treatment in intensive care units , 2001, Journal of General Internal Medicine.

[16]  E. Picard Legal liability of doctors and hospitals in Canada , 2007 .

[17]  M. Robinson,et al.  Matters of Spirituality at the End of Life in the Pediatric Intensive Care Unit , 2006, Pediatrics.

[18]  C. Sprung,et al.  The dying patient: new Israeli legislation , 2006, Intensive Care Medicine.

[19]  A. Gafni,et al.  What matters most in end-of-life care: perceptions of seriously ill patients and their family members , 2006, Canadian Medical Association Journal.

[20]  Abdulaziz Sachedina,et al.  End-of-life: the Islamic view , 2005, The Lancet.

[21]  G. Rubenfeld,et al.  Missed opportunities during family conferences about end-of-life care in the intensive care unit. , 2005, American journal of respiratory and critical care medicine.

[22]  P. Singer,et al.  Top 10 health care ethics challenges facing the public: views of Toronto bioethicists , 2005, BMC medical ethics.

[23]  J. Downie Unilateral Withholding and Withdrawal of Potentially Life-Sustaining Treatment: A Violation of Dignity under the Law in Canada , 2004, Journal of palliative care.

[24]  G. Rubenfeld,et al.  Family satisfaction with family conferences about end-of-life care in the intensive care unit: Increased proportion of family speech is associated with increased satisfaction* , 2004, Critical care medicine.

[25]  R. Arnold,et al.  Ethics and palliative care consultation in the intensive care unit. , 2004, Critical care clinics.

[26]  J. Curtis,et al.  Communicating about end-of-life care with patients and families in the intensive care unit. , 2004, Critical care clinics.

[27]  M. Bosek,et al.  When Religion May Be an Ethical Issue , 2004, Journal of Religion and Health.

[28]  T. Gilmer,et al.  Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. , 2003, JAMA.

[29]  A. Brett,et al.  "Inappropriate" treatment near the end of life: conflict between religious convictions and clinical judgment. , 2003, Archives of internal medicine.

[30]  M. Campbell,et al.  Impact of a proactive approach to improve end-of-life care in a medical ICU. , 2003, Chest.

[31]  T. Caulfield,et al.  Canadian health law and policy , 2002 .

[32]  C. Sprung,et al.  Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine , 2001, Critical care medicine.

[33]  M. Hunter Medical research under threat after Alder Hey scandal , 2001, BMJ : British Medical Journal.

[34]  R. Ackermann Withholding and withdrawing life-sustaining treatment. , 2000, American family physician.

[35]  D. Cook,et al.  Life support in the intensive care unit: a qualitative investigation of technological purposes. Canadian Critical Care Trials Group. , 1999, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[36]  J. Tulsky,et al.  Cardiopulmonary resuscitation on television: Miracles and misinformation , 1996 .

[37]  C E Phelps,et al.  The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit. , 1992, Heart & lung : the journal of critical care.