Management
Table 2. Categories of Disputed Treatments in Intensive Care Units
Category
Requests for potentially inappropriate
treatment
Requests for potentially
inappropriate treatment in
time-pressured situations
Definition
Treatments that have at least some
chance of accomplishing the effect
sought by the patient or surrogate
and are not proscribed, but clinicians
believe that competing ethical
considerations justify refusing to
provide the requested treatment
Treatments requested in the
setting of a rapidly deteriorating
clinical condition (which
precludes completion of the
conflict-resolution process),
which clinicians have a high
degree of certainty are outside
the bounds of accepted practice
Conflict-
Resolution
Process
Conflict resolution should be
accomplished via the process outlined
in Recommendation 3 and in Table 3.
As much of the conflict
resolution process (Table 3) as
possible should be carried out
for these requests.
• Check that facts are clear,
assumptions are verified,
and moral blind spots are
illuminated (Table 4).
• To the extent possible,
engage other clinicians to
ensure consensus regarding
the refusal.
• Empathically explain to
surrogates the reasons for
the refusal.
Examples
• A clinician believes ICU admission
for a person with end-stage
dementia and multiorgan failure is
inappropriate.
• A clinician believes it is
inappropriate to initiate dialysis in
a patient in a persistent vegetative
state.
• A clinician believes it is
inappropriate to continue
mechanical ventilation in a patient
with widely metastatic cancer.
• A clinician believes it is
inappropriate to place a
tracheostomy tube in a child with
prolonged respiratory insufficiency
and severe irreversible neurological
impairment.
• A surgeon refuses to perform
a laparotomy on a patient on
3 vasopressors with Child
C cirrhosis and a bowel
perforation
• A clinician refuses to initiate
ECMO on a frail, elderly
patient with multiple
comorbidities on maximal
circulatory support.
