Figure 1. Recommended Approach for Management of Disputed
Treatment Requests in Intensive Care Units
Can the physiological goals be achieved
with available medical treatments?
YES NO
• Clinicians should not provide these
treatments
• Clinicians should explain the situation
and provide emotional support for the
family/surrogate
Futile treatment
Is there an established, widely accepted
law, judicial precedent, or policy
that clearly governs provision of the
requested therapy?
YES NO
• Clinicians need not provide requested
treatment(s)
• Clinicians should explain the situation
and provide emotional support for the
family/surrogate
Legally Proscribed or Legally
Discretionary Treatment
Does the urgency of the clinical
situation preclude carrying out the
procedural resolution process and do
the clinicians involved have a high
degree of certainty that the requested
treatment lies outside the boundaries of
accepted practice?
YES NO
Potentially Inappropriate Treatment managed via
Procedural Resolution Process (Table 4)
• Clinicians need not provide requested treatment(s)
• Clinicians should explain the situation and provide
emotional support for the family/surrogate
Process favors clinician perspective
• Clinicians should provide the requested
treatment(s) or transfer care to a willing provider
• Clinicians should explain the situation and provide
emotional support for the family/surrogate
Process favors surrogate perspective
• Clinicians should strive
for a temporizing solution
to allow time to carry out
the procedural resolution
process.
• If not feasible, clinicians
should ensure that there is
consensus among involved
clinician and seek case
review to the extent possible.
• Clinicians should explain
the situation and provide
emotional support for the
family/surrogate.
Time-pressured potentially
inappropriate treatment
