Requests for Potentially Inappropriate Treatments In Intensive Care Units

Publication Date: March 2, 2015
Last Updated: September 2, 2022

Recommendations

Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultation.
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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 committee recommends the following approach to manage such cases:
  1. Expert consultation to continue negotiation during the dispute resolution process
  2. Give notice of the process to surrogates
  3. Obtain a second medical opinion
  4. Obtain review by an interdisciplinary hospital committee
  5. Offer surrogates the opportunity to transfer the patient to an alternate institution
  6. Inform surrogates of the opportunity to pursue extramural appeal
  7. Implement the decision of the resolution process
  • When time pressures (such as a rapidly deteriorating clinical condition) make it infeasible to complete all steps of the conflict-resolution process and clinicians have a high degree of certainty that the requested treatment is outside accepted practice, they should refuse to provide the requested treatment and endeavor to achieve as much procedural oversight as the clinical situation allows.
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There are two less-common situations for which the committee recommends different management strategies.
  • Requests for strictly futile interventions. 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. If disagreement persists, clinicians should generally obtain expert consultation to assist in conflict resolution and communication.
  • Requests for legally proscribed or legally discretionary treatments. “Legally proscribed” treatments are those that are prohibited by applicable laws, judicial precedent, or widely accepted public policies (e.g., organ allocation strategies). “Legally discretionary” treatments are those for which there are specific laws, judicial precedent, or policies that give physicians permission to refuse to administer them. In responding to requests for either legally proscribed or legally discretionary treatments, clinicians should carefully explain the rationale for treatment refusal and, if there is uncertainty regarding the interpretation and application of the relevant rule, should generally seek expert consultation to confirm accurate interpretation of the rule.
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The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used.
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Recommendation Grading

Overview

Title

Requests for Potentially Inappropriate Treatments In Intensive Care Units

Authoring Organizations

Publication Month/Year

March 2, 2015

Last Updated Month/Year

April 3, 2024

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Hospice, Hospital

Intended Users

Healthcare business administration, nurse, nurse practitioner, physician, physician assistant

Scope

Management

Keywords

intensive care, conflict resolution, Inappropriate Treatments, requests, ethics committees, Shared decision making, futility

Supplemental Methodology Resources

Data Supplement