Resolving conflict over treatment decisions sometimes impossible

Disputes between healthcare professionals and patients and/or their families about whether medical treatment is futile can be resolved through collaborative efforts and communication, say experts.

However, when the healthcare professional makes a unilateral decision, even according to best practice, it still may ultimately result in legal proceedings.

Writing in Mayo Clinic Proceedings, Christopher Burkle (Mayo Clinic, Rochester, Minnesota, USA) and colleagues review the role of early, clear communication, surrogate decision-makers, ethics committees, and other strategies employed to resolve this situation.

"Health care professionals in the United States have struggled with the importance of maintaining patient autonomy while attempting to practice under the guidance of treatments based on beneficial care," they say, adding that there there is still disagreement as to a true definition of futile care.

In the event of a conflict, the Uniform Health-Care Decisions Act stipulates that healthcare professionals must first communicate their decision to the patient or surrogate, allowing time for transfer to another provider.

"The surrogate's role is to 'stand in the shoes of the patient' and 'suppress his or her own judgment in favor of channeling what the [patient] would have done'," they write, in case the patient has lost capacity to make decisions.

While the American Medical Association suggests that choices to continue or withdraw/stop treatment should fall in line with that which "most reasonable persons would choose for themselves in similar circumstances," previous research indicates that surrogates are biased toward overestimating patients' desires for continued treatment.

Medical ethics committees are another means of resolving disputes between healthcare professionals and patients or their surrogates, and the authors cite the case in Canada of "Baby Joseph", whose parents requested a tracheostomy to enable their son to die at home. The physicians in the case refused, based on a lack of detected intact brainstem reflexes.

The decision by Ontario Consent and Capacity Board (CCB; akin to a medical ethics committee) not to offer the procedure was upheld in court, and indeed, the CCB has "repeatedly agreed with health care professionals' recommendations and has directed surrogates to accede to such recommendations to limit treatments or be replaced."

Baby Joseph's family subsequently appealed for help through the lay press and sought treatment for him abroad, in the USA.

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