The debate continues over the role healthcare providers should play in end-of-life care decisions.
Despite calls for healthcare leaders and providers to improve end-of-life care and planning, a physician and an ethics professor write differing opinions in the journal Chest about the involvement of doctors in the decision-making process.
Paul J. Hutchison, M.D., a Loyola University Medical Center critical care physician, says doctors should provide recommendations regarding goals of care to surrogates of dying patients in the ICU. "A physician has a responsibility to present surrogates with the plan of care he or she believes to be in the best application of a patient's authentic values and interests to a specific clinical situation," he writes.
But Robert M. Veatch, Ph.D., of Georgetown University's Kennedy Institute of Ethics, disagrees. Physicians, he writes, "have no basis for recommending treatment goals and, even if they did, they would tend to distort the decision-maker's perspective."
About 20 percent of Americans will receive care in an intensive care unit around the time of their death, and most deaths follow a decision to limit life-sustaining therapies, according to the point-counterpoint articles. Because many patients in the ICU can't make decisions about their own care, surrogates often speak on their behalf and collaborate with the treating physician to determine treatment goals. But in many cases, they have no idea what the patient would want. Recent research shows that fewer than half of terminally ill patients have advance directives. And one study showed that discussions about end-of-life care are most often hampered by patients and their family members who don't want to talk about such plans.
Many surrogates have no experience in making end-of-life decisions for someone else and struggle in that role, says Hutchison. Depressed and anxious over their loved one's illness, making decisions without a recommendation from the treating physician may be overwhelming, Hutchison argues. A physician's input can help family members, who have no medical background or training, to make decisions, but doctors should be open to other perspectives. "After all, the physician and surrogate are on the same team and with the same ultimate goal: respect for the interests and dignity of the critically ill patient," he writes.
On the other hand, Veatch says it is a mistake for physicians to recommend treatment goals and "many bad things can happen" if that occurs. Patients or their next-of-kin or other surrogates should make those decisions based on their beliefs and values, he says. For example, take a patient who is permanently unconscious from a head injury. Is it better to withdraw life support and let the dying process continue or to ventilate the patient on the grounds that human life is to be preserved? "Jack Kevorkian may choose one goal, the devout Orthodox Jew, the other," he writes.