Sunday, August 8, 2010

Curtis & Burt: Aim for Shared Decision-Making, Not Unilateral Refusal

In an new editorial in Critical Care Medicine [38(8): 1742-43], Randall Curtis and Robert Burt argue that we should not abandon the ideal of shared decision-making for even the tough futility conflicts.  They argue that when there is "persistent disagreement with families" that simply "requires even more persistent efforts to find a mutually acceptable resolution."  After all, they argue, the majority of conflicts can be resolved "through deliberate communication and negotiation."  Therefore, we ought not develop rules (e.g. Texas-style) that are "designed to settle" the rare intractable case because such rules could have "an unfavorable effect of the resolution of more common and less intractable disputes."  

Curtis and Burt do support "informed assent" as an "appropriate approach." But they do not endorse this to impose clinical references but rather only to facilitate "the family's unspoken and unspeakable [because of religion, culture, emotional burden] preferences."  Curtis and Burt fail to acknowledge or address that there will still be intractable disputes.  Presumably, they would agree with Robert Truog that physicians should just accede to family wishes in the rare remaining intractable cases.

1 comment:

Robert said...

Interesting. While I certainly am in favor of negotiation and mediation to resolve conflicts, what they seem to miss is that in some cases, these disputes really are intractable. Individual beliefs and even personality disorder may render a "rational" process impossible.

Regarding the issue of "rules" my only concern would be who implements them. If medical practitioners are driving this, professional ethics, one's license, and usually, a personal connection with the patient and family will mitigate against poor decisions. If the rules are ultimately employed by managed care personnel or administrators who lack this sort of connection or ethical/professional liability and peronal involvement, I would be concerned.

I don't think simply acceding to family wishes in intractable situations is viable as it would only reinforce being "intractable."