Collegial decision-making in palliative care units

Abstract

Summary Introduction Complex situations often occur during the practice of palliative medicine, whereby physicians and care teams might raise the question of the “appropriateness” of the applied investigations and treatments. The medical decision-making process in this context is difficult and the increasing number of treatment options available due to the progress of medical science contributes to the complexity of the task. Legal benchmarks are available to physicians to help guide their thinking and ensure the ethical purpose of care. The Act of April 22, 2005 on patients’ rights and end-of-life requires the establishment of a collegial process for decisions on limiting or discontinuing treatment in end-of-life patients who are unable to express their will. Method This study has been conducted in a palliative care unit with the aim of identifying the situations in which a collegial decision-making procedure is implemented by caregivers. The methodology for this part of the study consisted in analysing all the records of patients hospitalized in the facility during the year 2011 where it was noted that a collegial decision had been made. The second aim of this study was to understand, through semi-structured interviews, how doctors define collegial decision-making and for what decisions or situations they feel its implementation is necessary and relevant. We studied their key methods and compared these methods with those required under the Leonetti law. Results The analysis of 52 patient-records demonstrates that over 20% of collegial decisions do not concern treatment methods but the patient's outcome, and the 60% of cases the patient is able to express his/her will. The analysis of the five interviews held shows that doctors have varying definitions of collegial decision-making. Some define it by the presence of at least two doctors in the discussion, others by the quality of the discussion. All believe that the decision on discontinuing certain treatments such as anticoagulants, corticosteroids and antibiotics does not necessitate the routine application of a collegial decision-making process. There are situations where such a process is imperative, for example whether or not to discontinue mechanical ventilation and sedation. In other cases, the context determines whether collegial decision-making is necessary or not. Despite some limitations to this decision-process, the physicians interviewed can see benefits in the existence of this legal framework for end-of-life decision-making. Discussion End-of-life and the decisions that caregivers may need to make can become an issue due to the ethical issues involved. Physicians interpret the collegial decision-making procedure described by the Leonetti law in different ways. It seems that doctors have avoided falling into the trap of applying the collective procedure described in the Leonetti law “without substance”, and they have, through experience, tailored this tool to their requirements, within its legal framework. They have incorporated it into their work methods in a pertinent fashion, keeping an important focus on the ethical aspect of care and paying great attention to the reason behind each act or omission.