Demanding Providers, Patients and
Families: Exploring the ethics of
unrealistic requests for intervention.
Jason Lesandrini
Executive Director of Medical and Organizational
Ethics
WellStar Health System
Happy families are all alike; every unhappy family is unhappy in
its own way.
—Leo Tolstoy, Anna Karenina
Disclosure

We all have conflicts of interest

None are relevant today!
Objectives



Describe examples of unrealistic requests.
Explain the motivations behind unrealistic requests.
Identify solutions to address unrealistic request.
Ms. P



Ms. P presented to the hospital after coughing up blood
while visiting her family in GA. She was visiting from
Madagascar
Initial thoughts were patient had GI bleed—medical team
admits her for EGD because unsure of cause and she
have no option to have procedure outpatient.
She is also sent for CT scan of chest and abdomen


Read comes back from CT scan—metastatic cancer
1st day of hospital stay

Patient codes

ROSC is achieved
Ms. P

Family—patient’s sister and brother—are approached
about goals of care




Informed that patient has advanced cancer, there are no
interventions to offer to cure the cancer and that she will likely
die.
Sister states, “I am holding out that things will change.”
Brother states, “You do everything you have to.”
Team discusses code status with sister and brother, they
request the patient remain full code.
Is performing ACLS after patient arrests
futile?
35%
21%
Un
su
re
C.
44%
No
B.
Yes
No
Unsure
Ye
s
A.
Ms. P

Day 4



Patient codes three times
ROSC is achieved each time
Family approached about “care”


Brother persists in saying that he wants everything done.
Sister is holding out for divine intervention.
Is now performing ACLS after patient
arrests futile?
31%
3%
Un
su
re
C.
66%
No
B.
Yes
No
Unsure
Ye
s
A.
Ms. P

Day 9

Goes into renal failure requiring HD
Is providing dialysis futile?
44%
4%
Un
su
re
C.
52%
No
B.
Yes
No
Unsure
Ye
s
A.
Ms. P

Day 16





Patient is now intubated, on HD, on/off pressors
Head CT shows numerous strokes
Clinical Team updates family that patient will not leave the
hospital alive
Family states, “Continue”
Code Status— “We need to give her every chance for
recovery.”
Are further aggressive interventions futile?
25%
0%
Un
su
re
C.
75%
No
B.
Yes
No
Unsure
Ye
s
A.
Ms. P

Over the next 4 months




7 codes
On/Off HD
On/Off Pressors
Depending on intensivists—different measures are started or
stopped.
Ms. P

Day 173



Patient now has what appear to be cancerous tumors breaking
through her skin.
Increased ventilator support
Increased pressor support
Are further aggressive interventions futile?
12%
1%
Un
su
re
C.
86%
No
B.
Yes
No
Unsure
Ye
s
A.
Ms. P

Day 185

Patient codes

ROSC is not able to be obtained
Intimate Connection between Futility and
Unrealistic Requests

They are not synonymous


But connected
What does futile mean


Lots of consternation
Changes in language



Futile
Non-beneficial
Potentially Inappropriate Treatment
Responding to Requests for Potentially
Inappropriate Treatments…

ATS/AACN/ACCP/ESICM/SCCM Policy Statement

Supports a focus on prevention strategies
Agrees with the move to conflict resolution mechanism.

Video

https://www.youtube.com/watch?v=wGdhc9k07Ms
Is it futile for Lloyd to pursue Mary?
39%
1%
Un
su
re
C.
59%
No
B.
Yes
No
Unsure
Ye
s
A.
What does it really mean
A goal
An action aimed at achieving the goal
Virtual certainty that the action will fail.
1.
2.
3.
Causes of unrealistic request

Patient/Family requests



Communication/Comprehension
Provider Practice
Miracles
Communication/Comprehension

Sources of unrealistic expectations can result from
inaccurate presentation of information or interpretation
of information.
Communication
Communication with each other
Comprehension
Miracles
Provider Practice

Inconsistent Care amongst providers in same specialty

Nephrology


RPA Guidelines
61% of providers are aware of RPA guidelines

50% of those aware use it
Provider Practice

Leads to variation in practice

“Professional Prudence is defined by actual or accepted practice within a
profession”

Actions speak louder than words. Thus, we create our own animal
Provider unrealistic request
Mr. J

Presented to outpatient ENT office for review of large
mass diagnosed on CT scan.



Diagnosis: Cancerous mass requiring resection and repair of
esophagus
Significant recovery time and likelihood of trachestomy, PEG
and rehab.
Patient with wife, consents to surgical intervention
Mr. J

Admitted to hospital for surgery


Consent is re-obtained with patient and wife
Surgery is performed without complications
Mr. J

Day 7



Per clinical team, patient is making progress on vent weaning
Wife informs surgeon that patient is expressing—shaking head
yes/no—concern about continuing.
Surgeon tells wife, “I am not sure he understands what he is
saying.”

Wife states, “I am worried that he does not want to continue.”
Mr. J

Day 14

Recovery has slowed


Patient has intermittently been refusing interventions
Surgeons tells wife, “He agreed to the treatment before the surgery,
he does not have a choice.”

Instructs nursing and ancillary staff to force interventions on patient.
Mr. J

Day 20

Wife informs surgical team that patient is requesting to be
extubated

Surgeon interacts with patient and expresses the same.

Surgeon tells wife, “I won’t do it. He agreed to the treatment and
rehab.”

“I won’t kill him.”
Mr. J

Day 27

Conversation with patient, wife, and surgical services



Patient clearly states that he does not want intubation to continue.
Expressing understanding that he will likely die
Surgeon states that he will not participate.
Mr. J

Day 31

Surgeon signs off case and tells Intensivists


“You can do whatever you want.”
Patient is extubated and dies within 24 hours.
Causes of unrealistic request

Provider requests



Difference in Values
Metrics
Healers
Difference in values
Metrics
Healers
Resolution
Handling Miracles

AMEN!




Affirm
Meet
Educate
No matter what
AMEN

If patient says that they are hoping for a miracle.




A=Affirm the patient’s belief.Validate his or her position: “Ms X,
I am hopeful, too.”
M=Meet the patient or family member where they are: “I join
you in hoping (or praying) for a miracle.”
E=Educate from your role as a medical provider: “And I want
to offer some information as a medical provider.”
N=No matter what, assure the patient and family you are
committed to them: “No matter what happens, I will be with
you every step of the way.”
Only Healers Shall Enter
Clarity on Standards of Care

There are ways to limit unrealistic requests



Limits are set by existing standards of care.
No ethical obligation to provide treatment because someone
wants it.
These requests for care—usually requests for
“everything”—should explore the meaning of everything.

Everything within standard of care might already being done.
Communication/Comprehension Strategies
Clarity on Standards of Care

We have to implement protocols for care that establish
clear plans for providers and patients

PVS patients and dialysis
False Choices

What does disclosure require

Disclosure of all options—even those outside of standard of care?



False choices=asking patients and families to reject interventions that
have no clinical indication and that can provide no real benefit.



Ethically, I do not think you are required to do disclose all options.
Doing so, presents false choices.
Presenting false choices diminishes rather than enhances the exercise of
authentic decision making
Also, abdicates the professional’s responsibility to exercise clinical
judgment and to guide patients and families in ways that make clinical
sense.
Death is not a negotiable outcome in some
situations
Paternalism
Questions
Thank you
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