Background: Clinicians face substantial challenges in limiting life-prolonging interventions (e.g., ICU admission, life-sustaining treatments, invasive procedures) near the end of life, even when they judge these interventions to be non-beneficial [1-3]. The objective of our study was to empirically derive a descriptive framework of decision-making approaches used by clinicians to limit (i.e., withhold or withdraw) life-prolonging interventions felt to be non-beneficial.
Methods: As part of a larger ethnography at three academic medical centers [4], we conducted in-depth semi-structured interviews (n=104) with clinicians (e.g., physicians, nurses, social workers) to explore clinical practices and decision-making around end-of-life care. We developed an initial framework using clinical, bioethics, and decision-making literature. We subsequently analyzed interviews using both inductive and deductive methods to identify and describe distinct approaches to limiting life-prolonging interventions and clinician perspectives on the utility and ethical justification of each approach.
Results: When clinicians judged that life-prolonging interventions were not in the patient’s best interest, they generally attempted to reach an agreement with the patient/surrogate to limit interventions using one of three primary approaches: (1) Providing non-directive choice, (2) Presenting a recommendation, or (3) Seeking informed assent. When clinicians anticipated that an agreement could not be reached, they resorted to alternate approaches: (4) Deferring to the patient/surrogate, (5) Not offering interventions, or (6) Invoking a policy-supported process to limit interventions. Clinicians described substantial uncertainty about navigating these scenarios, expressing varied and sometimes contradictory viewpoints about the utility or ethical acceptability of each approach.
Conclusions: Clinicians use a complex set of approaches to navigate challenges in limiting life-prolonging interventions near the end of life. Only some of these approaches conform to professional guidance regarding shared decision making [5] or conflict resolution [6]. Clinicians, healthcare leaders, and policymakers can leverage this framework to better characterize if, when, and how each approach can be used to limit life-prolonging interventions.