The importance of showing our work: Process transparency in dispute resolution

An Ovid search for use of the term “medical futility” since 1980 returns 7,467 results. Although this subject has received much academic attention, there remain significant gaps in our knowledge about how best to resolve conflicts with surrogates requesting treatments that clinicians believe should not be provided. Most of the existing literature can be assigned to one of three clinician-centric categories: 1) descriptions of common surrogate requests and theoretical resolution strategies, 2) communication interventions to prevent disputes, and 3) explorations of how requests for a potentially inappropriate treatment make clinicians feel. There have been comparatively few investigations into how surrogates experience these disputes outside of the contentious situations where conflicts rise to the level of public discourse, as in the cases of Charlie Gard and Jahi McMath.

In 2015, a policy statement approved by multiple critical care societies, including the American Thoracic Society, proposed using the broader term “potentially inappropriate” to encompass all situations in which clinicians believe competing ethical considerations justify withholding treatments. This statement outlined a multistep process for responding to surrogates’ requests for such interventions in intensive care units (ICUs). In this issue of AnnalsATS, Bailoor and colleagues (pp. 738–743) explore the reactions of uninvolved lay citizens to clinical vignettes concerning resolution of requests for potentially inappropriate treatment via this process. A nationwide sample of 1,191 adults reviewed two vignettes in which clinicians withheld one of two treatments against the wishes of the patient’s daughter: chemotherapy in the setting of metastatic cancer and hemodialysis after a devastating intracerebral hemorrhage. Half of the respondents were randomized to receive “process information.” These respondents were told that the team obtained a second opinion from an independent physician, had the case reviewed by the hospital ethics committee, and explored whether the patient could be transferred to another institution. The other half of the respondents did not receive this process information. The primary outcome was a four-point Likert scale assessing responses to the question, “How appropriate do you find the decisions made by the doctors?”