New research published in the August 15 issue of the American Journal of Respiratory and Critical Care Medicine finds that some caregivers of critical care patients [removed]prefer doctors to keep their opinions on life support decisions to themselves[/removed]. Researchers found that surrogates are nearly split in half when it comes to the amount of guidance they want from physicians in making end-of-life medical decisions for critically ill patients.
“What we found was that, while a slight majority did prefer doctors to help them make those difficult decisions, many felt that it was a decision they wanted to make without guiding input from doctors other than an explanation of the options,” said lead author Douglas B. White, MD, of the University of Pittsburgh Medical Center, in an announcement about the findings.
“This [an end-of-life medical decision] puts an enormous emotional burden on surrogates; not only are they losing a loved one, they also may feel burdened by guilt about allowing the patient to die,” said White in an announcement about the study. “It was therefore assumed by some in the medical community that a doctor’s dispassionate advice could reduce some of that burden and help surrogates make a good decision with less second-guessing themselves. However, there was little or no research to support this assumption.”
The research team set out to test this assumption, which, according to the American Thoracic Society (ATS), was recently formalized as a recommendation by a number of critical care societies. The research team asked surrogates of critical care patients to watch and respond to two videos. The videos depicted a hypothetical ICU “family conference” in which surrogates must decide whether to continue or withdraw life support from a loved one who has a small chance of survival with continued intervention, but a high likelihood of severe functional impairment in the long-term, including dependence on a ventilator. Both videos were identical in all ways except one: in one version, the doctor says that the most important thing is for the surrogate to “make the choice that’s consistent with [the patient’s] values,” but states that only the surrogate could make that decision; in the alternate version, the doctor offers his opinion that the patient would likely not have wanted to continue aggressive treatment given the likely outcome.
A total of 169 surrogates from four ICUs at the University of California San Francisco Medical Center were recruited for the study. White and colleagues found that 56% of surrogates expressed a preference for the version in which the physician offered an opinion to limit life support. A slight minority, 42%, preferred no recommendation, and the final 2% had no preference.
“This is an important article that has changed my clinical practice,” said J. Randall Curtis, MPH, MD, president of the ATS. “I had previously assumed that almost all families would want physicians’ recommendations, but these findings indicate that there is no such consensus among surrogates. I suspect that physicians can do more harm by withholding a recommendation that is desired than by providing a recommendation that is not desired, but this study suggests we should ask rather than assume.”
“A very important part of American bioethics is respecting patient’s choices,” said White. “The family’s most important job when acting as a surrogate decision maker is to give voice to the patient’s values. I think our research highlights that the physician’s job is to be flexible enough and insightful enough to respond to the surrogate’s individual needs for guidance.”