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Are Physicians' Recommendations to Limit Life Support Beneficial or Burdensome?

Bringing Empirical Data to the Debate

¹ Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, School of Medicine; San Francisco; ² Program in Medical Ethics, Department of Medicine, University of California, San Francisco, San Francisco; ³ School of Medicine, University of California, San Francisco; and ⁴ Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, San Francisco, California

Correspondence and requests for reprints should be addressed to Douglas B. White, M.D., M.A.S., University of California, San Francisco Program in Medical Ethics 521 Parnassus, Suite C-126, Box 0903 San Francisco, CA 94143. E-mail: douglas.b.white{at}ucsf.edu

Rationale: Although there is a growing belief that physicians should routinely provide a recommendation to surrogates during deliberations about withdrawing life support, there is a paucity of empirical data on surrogates' perspectives on this topic.

Objectives: To understand the attitudes of surrogate decision-makers toward receiving a physician's recommendation during deliberations about whether to limit life support for an incapacitated patient.

Methods: We conducted a prospective, mixed methods study among 169 surrogate decision-makers for critically ill patients. Surrogates sequentially viewed two videos of simulated physician–surrogate discussions about whether to limit life support, which varied only by whether the physician gave a recommendation.

Measurements and Main Results: The main quantitative outcome was whether surrogates preferred to receive a physicians' recommendation. Surrogates also participated in an in-depth, semistructured interview to explore the reasons for their preference. Fifty-six percent (95/169) of surrogates preferred to receive a recommendation, 42% (70/169) preferred not to receive a recommendation, and 2% (4/169) felt that both approaches were equally acceptable. We identified four main themes that explained surrogates' preferences, including surrogates' perceptions of physicians' appropriate role in life or death decisions and their perceptions of the positive or negative consequences of a recommendation on the physician–surrogate relationship, on the decision-making process, and on long-term regret for the family.

Conclusions: There is no consensus among surrogates about whether physicians should routinely provide a recommendation regarding life support decisions for incapacitated patients. These findings suggest that physicians should ask surrogates whether they wish to receive a recommendation regarding life support decisions and should be flexible in their approach to decision-making.

Key Words: surrogate decision-making • physician recommendations • empirical ethics

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Multiple pulmonary and critical care professional societies recently recommended that physicians should routinely provide recommendations to surrogates about whether to limit life support. What This Study Adds to the Field The current study reveals that there is no consensus among surrogates about whether physicians' recommendations are desired for value-sensitive decisions about withdrawing life support. These empirical findings suggest that recent professional society guidelines may not be in line with the diverse perspectives of families in intensive care units.

 

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