O-164 The emotional and ethical complexity of end of treatment in ART

Abstract

Abstract In the context of Assisted Reproductive Technology (ART), the decision to end the treatment is very complex and involves emotional and ethical dimensions. It should occur after a series of failed attempts and when “the chances for a successful outcome are so low that it is in the patient’s best interest to stop any further attempt at it”1. The lack of a clearly defined biological endpoint makes the decision to end treatment extremely challenging and is one of the most complex bad news within the doctor-patient relationship. The decision to end treatment can be experienced by patients as an existential failure; they are overwhelmed by all sorts of emotions related to the acknowledgment that the pregnancy they hoped for might eventually never happen. When treatment is interrupted, hope could be lost with feelings of intense sorrow, and failing to become a parent requires rethinking a new identity. Patients who end ART treatment may experience a crisis characterized by shock, denial, anger, frustration, and loss of control. Many patients approach ART treatment thinking that repeated attempts will sooner or later lead to the long-awaited pregnancy. This attitude could turn into “over-persistence”, the condition in which patients insist on continuing ART treatment with very low or any chance of success. According to the literature, doctors may mitigate patients’ emotional distress related to the end of treatment (EoT) through effective communication, which has the potential to facilitate the process of acceptance and reduce psychological suffering. Likewise, physicians may experience intense emotions (e.g., frustration, denial). Clinicians reported feelings ranging from the idealization of the process to impotence, and these emotions intertwined with a sense of duty could influence decisions about ART treatment and lead to compulsive use of ART procedures. Clinicians remain fully aware of the probability of success and perceive patients’ expectations as a burden, resulting in performance anxiety. The decision to end unsuccessful ART treatment also involves ethical aspects. In particular, the decision to end treatment raises the dilemma between beneficence and patient autonomy. The request for (over)persisting ART treatment may come from patients with a strong desire for parenthood, who do not accept the possibility of giving up on biological pregnancy. On one hand, any choice about EoT must be in accordance with the patient’s self-determination; on the other hand, doctors should consider the patient's beneficence and favorable risk/benefit ratio. EoT should be considered as a matter of proportionality of care, recognizing that benefits may be less than the medical, economic, but especially psychophysical burdens. The value of distributive justice and equity must also be addressed. Owing to rising healthcare costs, health professionals have an ethical duty to manage medical services, eliminating all those non-essential procedures requiring a waste of resources and/or time with few or no significant results. 1. Boivin J, Takefman J, Braverman A. Giving bad news: ‘It’s time to stop’. In Macklon N. IVF in the medically complicated patient: A guide to management. Milton Park, UK: Taylor & Francis Group, 2005. p. 233-240.