Chest
EDITORIALSPOINT/COUNTERPOINT EDITORIALSPoint: The Ethics of Unilateral “Do Not Resuscitate” Orders: The Role of “Informed Assent”
Section snippets
The Value and Risk of Informed Assent
In the critical care setting, there are specific circumstances when some standard therapies, such as cardiopulmonary resuscitation, may not provide any benefit to the patient. In these circumstances, are clinicians always obliged to obtain informed consent from patients or family members to withhold or withdraw such therapies? Because the process of obtaining informed consent may cause considerable distress for some patients and family members, we contend that obtaining informed assent—when the
Three Categories of Withholding or Withdrawing Life Support
In the ICU, we can identify three categories of decisions to withhold or withdraw life-sustaining therapies that clinicians believe are clearly not indicated; the concept of informed assent is not equally relevant for all three categories. The first category is withholding treatments that patients or family members are not likely to expect for the patients' specific condition (for example an exploratory laparotomy or activated protein C for a moribund patient with severe septic shock and
References (26)
- et al.
The illusion of futility in clinical practice
Am J Med
(1989) - et al.
The seriously ill hospitalized patient: preferred role in end-of-life decision making?
J Crit Care
(2003) - et al.
Use of intensive care at the end of life in the United States: an epidemiologic study
Crit Care Med
(2004) - et al.
Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit
N Engl J Med
(2003) - et al.
End-of-life practices in European intensive care units: the Ethicus Study
JAMA
(2003) - et al.
A national survey of end-of-life care for critically ill patients
Am J Respir Crit Care Med
(1998) - et al.
Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care; Brussels, Belgium, April 2003
Intensive Care Med
(2004) Withholding and withdrawing life-sustaining therapy
Ann Intern Med
(1991)Consensus statement of the Society of Critical Care Medicine Ethics Committee regarding futile and other possibly inadvisable treatments
Crit Care Med
(1997)- et al.
Medical futility: its meaning and ethical implications
Ann Intern Med
(1990)
Medical futility: response to critiques
Ann Intern Med
Use of the medical futility rationale in do-not-attempt-resuscitation orders
JAMA
Cited by (76)
Postcardiotomy Extracorporeal Membrane Oxygenation: Narrative Review Navigating the Ethical Issues
2022, Journal of Cardiothoracic and Vascular AnesthesiaPrinciple of therapeutic proportionality in the decision of orotracheal intubation and invasive mechanical ventilation in patients with serious COVID-19
2022, Acta Colombiana de Cuidado IntensivoEvolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients
2022, Journal of Pain and Symptom ManagementVeno-venous extracorporeal membrane oxygenation allocation in the COVID-19 pandemic
2021, Journal of Critical CareCitation Excerpt :For example, the Texas Advanced Directives Act of 1999 justifies withdrawing life-sustaining therapy against the wishes of surrogate decision makers so long as physicians account for patient autonomy, ensure good stewardship of patient resources, and avoid harm to patients [56,57]. This could be considered “informed non-dissent,” in which surrogates agree interventions should be limited but prefer to leave the actual decision to continue or withdraw therapy to physicians [58,59]. Informed non-dissent may be a palatable approach for both clinicians and recipients of care, though must be a legally acceptable strategy in an individual institution.
Ethical Considerations for Mechanical Support
2019, Anesthesiology ClinicsPragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals
2019, The Lancet Respiratory MedicineCitation Excerpt :When potentially inappropriate treatments are requested, the guidelines recommend that clinicians communicate and advocate for the treatment plan they believe is most appropriate and if needed, implement a process of conflict-resolution.99 One approach that might minimise the provision of potentially inappropriate interventions in an ICU is to offer patients with decisional capacity, or family members if the patient does not have decisional capacity, the option of deferring decisions to clinicians.100,101 Patients and their family members vary in their desire for decisional control.102,103
The authors have no conflicts of interest to disclose.
Editor's Note:As part of our ongoing Medical Ethics series, we offer this POINT/COUNTERPOINT Debate and frame it with the following vignette: At Grand Rounds regarding end-of-life issues, a visiting professor offered that when cardiopulmonary resuscitation (CPR) is unlikely to promote survival with a reasonable quality of life, he shares his assessment with the patient. If the patient does not object, he enters a “no CPR” order in the patient's medical record.