Harming patients by provision of intensive care treatment: is it right to provide time-limited trials of intensive care to patients with a low chance of survival?

Thomas M Donaldson

doi:10.1007/s11019-020-09994-9

Thomas M Donaldson

Open Access

https://doi.org/10.1007/s11019-020-09994-9

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Journal: Medicine, Health Care and Philosophy	Publication Date: Jan 15, 2021
Citations: 9	License type: open-access

Affiliation: University of Manchester

Abstract

Time-limited trials of intensive care have arisen in response to the increasing demand for intensive care treatment for patients with a low chance of surviving their critical illness, and the clinical uncertainty inherent in intensive care decision-making. Intensive care treatment is reported by most patients to be a significantly unpleasant experience. Therefore, patients who do not survive intensive care treatment are exposed to a negative dying experience. Time-limited trials of intensive care treatment in patients with a low chance of surviving have both a small chance of benefiting this patient group and a high chance of harming them by depriving them of a good death. A ‘rule of rescue’ for the critically unwell does not justify time-limiting a trial of intensive care treatment and overlooks the experiential costs that intensive care patients face. Offering time-limited trials of intensive care to all patients, regardless of their chance of survival, overlooks the responsibility of resource-limited intensive care clinicians for suffering caused by their actions. A patient-specific risk–benefit analysis is vital when deciding whether to offer intensive care treatment, to ensure that time-limited trials of intensive care are not undertaken for patients who have a much higher chance of being harmed, rather than benefited by the treatment. The virtue ethics concept of human flourishing has the potential to offer additional ethical guidance to resource-limited clinicians facing these complex decisions, involving the balancing of a quantifiable survival benefit against the qualitative suffering that intensive care treatment may cause.

Highlights

The ageing population of many countries has led to more elderly and increasingly co-morbid patients accessing healthcare services, and intensive care is no exception
The prediction of which patients will survive their critical illness with intensive care treatment has proved unreliable (Detsky et al 2017), and the desire to ensure that no-one who may survive is denied intensive care treatment has led to calls for trials of increasing duration (Shrime et al 2016), despite the acknowledged risk of patient discomfort (Quill and Holloway 2011)
86.5% of survivors of intensive care treatment retrospectively agree with the decision that was made to mechanically ventilate them (Mendelsohn et al 2002), and 75.9% of survivors would choose to go through mechanical ventilation again (Guenter et al 2006)

Summary

Introduction

The ageing population of many countries has led to more elderly and increasingly co-morbid patients accessing healthcare services, and intensive care is no exception. This means that the provision of intensive care treatment has the potential to cause significant harm to patients who do not survive their critical illness, by depriving these patients of a better dying experience that might otherwise have been provided for them by palliative care.

Results

Conclusion