End-of-Life Advice Not Always Welcome

TUESDAY Aug. 25, 2009 -- When deciding whether to turn off life support for a loved one, family members aren't always interested in their doctor's advice, new research shows.

The finding runs counter to assumptions among critical-care providers that families making such a heart-wrenching choice would welcome a physician's impartial opinion.

Critically ill patients who don't have advance directives often require others to make medical decisions for them, said study author Douglas B. White, of the University of Pittsburgh Medical Center.

Family members often make the decision based on what they believe the patient would have wanted.

"This 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," White said. "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."

Researchers showed videos to 169 surrogates recruited from intensive care units at University of California San Francisco Medical Center. The videos depicted a dramatized "family conference" in which surrogates must decide whether to withdraw life support from a loved one who has a small chance of survival with continued treatment, but a high likelihood of being functionally impaired and needing a ventilator.

In one video, the doctor tells the surrogate to make the choice that's consistent with the patient's values, and that only the surrogate knows what that is. In the second video, the doctor tells the surrogate that the patient probably wouldn't want continued attempts to keep him or her alive.

About 56 percent of surrogates said they preferred the video in which the physician offered an opinion to limit life support, while 42 percent preferred the video in which no recommendation was offered. Two percent had no preference.

The study appears in the August 15 issue of the American Journal of Respiratory and Critical Care Medicine.

Dr. J. Randall Curtis, president of the American Thoracic Society, said the paper challenges current assumptions about dealing with families in end-of-life situations.

"This is an important article that has changed my clinical practice," said Curtis, a professor of medicine and section head of pulmonary and critical care medicine at Harborview Medical Center in Seattle. "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."

About 51 percent of the surrogates who wanted their doctor's advice believed that it was the doctor's job to provide that opinion. Nearly 79 percent who preferred not to receive the advice saw it as overstepping.

"A very important part of American bioethics is respecting patients' choices," White said. "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."

More information

The Family Caregiver Alliance has more on making end-of-life decisions.

Posted: August 2009


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