Rapidly evolving therapies can challenge a physician’s understanding of advanced-stage disease and add complexity to end-of-life decision-making, yielding divergent recommendations from colleagues. Two physician experts examine when it is appropriate for a doctor assuming care at a critical juncture to challenge established goals of care. They also provide suggestions for moving forward in the best interests of the patient.
The AMA Code of Medical Ethics provides guidance on end-of-life care, such as chapter 5, “Opinions on Caring for Patients at the End of Life,” which covers topics such as advance care planning, advance directives and orders not to attempt resuscitation.
Following are highlights from an article in the AMA Journal of Ethics® (@JournalofEthics) by Shyoko Honiden, MD, and Jennifer Possick, MD, associate professors of medicine in the Section of Pulmonary, Critical Care and Sleep Medicine of the Department of Internal Medicine at the Yale School of Medicine. Using a hypothetical case involving a 65-year-old man with stage IV non-small cell lung cancer, they explored whether and when it is appropriate for physicians new to a case to counsel patients and surrogates to revisit care decisions.
Personal and systemic forces
What motivates a physician to pursue or reject aggressive care is not well understood, but it could include personal forces, such as beliefs, biases and knowledge deficits, the authors wrote.
“Although this issue is complex and reflects many factors, some studies have highlighted the influence of physician practice variation,” they added, noting research that found practicing in a smaller independent office was a predictor of more aggressive care for cancer patients.
Meanwhile, there are system-level forces in play, such as clinical momentum.
“Akin to a biologic cascade like hemostasis, an initial clinical circumstance prompts therapeutic actions that in turn propagate more interventions, even when clinical circumstances have changed,” the authors wrote.
Ways to move forward
“There is very little in the literature about how to resolve treatment conflict among clinicians,” the authors wrote, noting that some concepts from futility disputes may relate, although futile care is an extreme scenario.
That having been said, they recommended the following approaches.
Distinguish between professional disagreement and moral objection. If there is evidence that information provided about the prognosis by the physician handing off was incorrect or that communication was ineffective or coercive, the physician new to the case is obligated to revisit the goals-of-care discussion. “However, if no such concern exists, placing a grieving family at the center of an intellectual conflict is unnecessarily destructive,” the authors said.
Acknowledge prognostic uncertainty. “In the shared decision-making model, respect for patient autonomy is tempered by physician expertise and judgment, and decisions are neither solely vested with the patient nor paternalistically with any one clinician,” the authors wrote. “Withholding divergent opinions, particularly at critical decision points, can undermine effective partnerships.”
Uphold the principles of beneficence and nonmaleficence. “It is important for physicians to be able to navigate a medical environment primed to propagate clinical momentum and to avoid imposing unwanted aggressive care upon patients and their families,” the authors said.
Involve another, impartial physician. “If deemed necessary to re-involve family, both physicians should be present to facilitate discussion in a way that does not jeopardize the existing trust … and avoids undue emotional distress,” the authors wrote. If the family remains comfortable with the original decision but the physician new to the case remains troubled, reassigning the patient to another team who can execute the plan could be the best course of action.
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