7.1.6 Demands for Inappropriate Treatment
Stephen Workman, MD, MSc, FRCPC
- To provide an understanding of the frequency, importance and reasons for demands for treatment
- To examine the moral and legal obligations on physicians to provide requested treatment and inappropriate treatment
- To determine how one should respond to a demand for treatment that a physician considers inappropriate, and yet endeavour to preserve the patient-physician relationship
- To offer a framework to guide communication with family members who are demanding treatment
A female patient with advanced Alzheimer's disease is bedridden and non-communicative. Two prior episodes of aspiration pneumonia have been successfully treated in the intensive care unit. One week after discharge to the medical ward, the woman's saturations are 87% on 100% oxygen. The X-ray shows infiltrates consistent with recurrent aspiration. The two children, one of whom has power of attorney, want their mother re-intubated and readmitted to the intensive care unit.
A male patient who had previously chosen not to receive palliative chemotherapy for an advanced malignancy opted instead to receive homeopathic treatments at home. The man returns to hospital near death. The oncologist writes that the patient is now too sick to withstand chemotherapy. The admitting physician asks the spouse if cardiopulmonary resuscitation (CPR) is to be performed in the event that the patient suffers a cardiac arrest. The spouse states that there is a clear preference for it to be performed in order to allow the homeopathic treatments time to work.
- What are the frequency, importance and reasons for requests, or demands, for treatment?
- What moral and legal obligations exist for physicians when addressing demands for treatment?
- How should you respond to demands for treatment that you consider inappropriate?
- In the face of sustained disagreement, what resources can guide your communication with family members?
Demands for life-sustaining treatment are the most important ethical problem facing physicians today. Physicians must strive to ensure that their recommendations and assessments are within the standard of care. In end-of-life care situations, they must ensure that compassionate care for patients and family members is provided. Persistent demands for treatment must be carefully explored. Disagreements based upon differences in values should be respected and opened up to external review. Keys to managing treatment demands include the following:
- Develop a clear assessment of prognosis and options and obtain second opinions and up to-date information whenever necessary. Provide treatment options within the context of the patient's overall condition, acknowledging that death is not a negotiable outcome when necessary.24
- Have a structured meeting with patients and/or their family members of suitable duration. Attentive listening and provision of emotional support can resolve disagreements and/or make it less likely that disagreements will escalate into conflict. Recognize and accommodate the very significant levels of stress that family members may experience in end-of-life care situations.
- Determine if you wish to use shared decision-making. If this is the case, consider delimiting some options at the outset. ("Clearly CPR could never be effective, but some options include. . . .") The expert assessment that a patient cannot be saved cannot be shared with family members. Once patients are recognized to be dying, give family members the bad news that no treatment will save the patient and provide emotional support to facilitate acceptance. After this shared view is established, negotiate decisions to withhold or withdraw death-prolonging treatments.
- Intractable disagreements are best viewed as arising from differing visions of what is the best for the patient. The importance of maintaining patient comfort and dignity to the best of one's abilities can help establish common ground. No one wants family members to suffer unnecessarily. Throughout the negotiation process, take efforts to build and maintain a relationship with distraught family members.
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