Assignment: Care Medicine Volume
In some cases, the patient/surrogate may wish to exercise significant authority in decision-making. In such cases, the clinician should understand the patient’s values, goals, and preferences to a sufficient degree to ensure the medical decisions are congruent with these values. The clinician then determines and presents the range of medically appropriate options, and the patient/surrogate chooses from among these options. In such a model, the patient/surrogate bears the majority of the responsibility and burden of decision-making. In cases in which the patient/surrogate demands interventions the clinician believes are potentially inappropriate, clinicians should follow the recommendations presented in the recently published multiorganization policy statement on this topic (14).
In other cases, the patient/surrogate may prefer that clinicians bear the primary burden in making even difficult, value-laden choices. Research suggests that nearly half of surrogates of critically ill patients prefer that physicians independently make some types of treatment decisions (10–13). Further, data suggest that approximately 5–20% of surrogates of ICU patients want clinicians to make highly value-laden choices, including decisions to limit or
1334 American Journal of Respiratory and Critical Care Medicine Volume 193 Number 12 | June 15 2016
withdraw life-prolonging interventions (12, 13). In such cases, using a clinician-directed decision-making model is ethically justifiable (15–24).
Employing a clinician-directed decision-making model requires great care. The clinician should ensure that the surrogate’s preference for such a model is not based on inadequate information, insufficient support from clinicians, or other remediable causes. Further, when the surrogate prefers to defer a specific decision to the clinician, the clinician should not assume that all subsequent decisions are also deferred. The surrogate should therefore understand what specific choice is at hand and should be given as much (or as little) information as the surrogate wishes. Under such a model, the surrogate cedes decision-making authority to the clinician and does not need to explicitly agree to (and thereby take responsibility for) the decision that is made. The clinician should explain not only what decision the clinician is making but also the rationale for the decision, and must then explicitly give the surrogate the opportunity to disagree. If the surrogate does not disagree, it is reasonable to implement the care decision (19–24). Readers may review references 19–24 for detailed descriptions and ethical analyses of clinician-directed decision-making.
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