The American Thoracic Society has issued new guidelines regarding requests for treatments that clinicians believe should not be implemented. Key recommendations:
- Be proactive in communicating treatment plans and involving specialists in ethics and palliative care, in an attempt to “avoid intractable conflicts.”
- Limit the use of the word “futile” to interventions “that simply cannot accomplish the intended physiologic goal.” These should not be provided.
- Use the term “potentially inappropriate” 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.”
- Establish and follow a conflict-resolution process for these “potentially inappropriate” measures, including:
- Involvement of experts in ethics and conflict mediation
- Informing surrogates of the process
- Obtaining a second medical opinion
- Review by an interdisciplinary hospital committee
- Offer transfer to another institution
- Inform surrogates of the opportunity for external appeal
- If time is of the essence, limiting the opportunity for a formal process to reach a conclusion, clinicians need not provide what they consider to be “inappropriate” care provided the measures in question are outside the standard of care, other clinicians agree (when they can be engaged), assumptions and potential moral blind spots are identified and addressed, communication with surrogates is maintained, and the clinician’s decision is based on his best judgment of his professional obligation to the patient.
- In relatively rare situations, a measure may be prohibited by law—in which case it should not be provided—or the law may explicitly give clinicians discretion regarding use, in which case the physician may use her best judgment. In both cases, good communication with surrogate decision makers remains paramount.
- Physicians should take the initiative to help inform public policy discussions regarding these matters.
Overall, the statement seems balanced and reasonable. The narrow definition of “futile” and the distinction of “potentially inappropriate,” as cumbersome as the latter term may be, does appear helpful.