"Everything has been tried and his heart can't recover…": A Descriptive Review of "Do Everything!" in the Archive of Ontario Consent and Capacity Board.
Bioethics
Communication
Critical care
Goals of care
Palliative care
Journal
BMC medical ethics
ISSN: 1472-6939
Titre abrégé: BMC Med Ethics
Pays: England
ID NLM: 101088680
Informations de publication
Date de publication:
27 06 2022
27 06 2022
Historique:
received:
21
12
2021
accepted:
24
05
2022
entrez:
27
6
2022
pubmed:
28
6
2022
medline:
30
6
2022
Statut:
epublish
Résumé
In end-of-life situations, the phrase "do everything" is sometimes invoked by physicians, patients, or substitute decision-makers (SDM), though its meaning is ambiguous. We examined instances of the phrase "do everything" in the archive of the Ontario Consent and Capacity Board (CCB) in Canada, a tribunal with judicial authority to adjudicate physician-patient conflicts in order to explore its potential meanings. We systematically searched the CCB's online public archive from its inception to 2018 for any references to "do everything" in the context of critical care medicine and end-of-life care. Two independent assessors reviewed decisions, collected characteristics, and identified key themes. Of 598 cases in the archive, 41 referred to "do everything" in end-of-life situations. The phrase was overwhelmingly invoked by SDMs (38/41, 93%), typically to advocate for life-prolonging measures that contradicted physician advice. Physicians generally related "doing everything" to describe the interventions they had already performed (3/41, 7%), using it to recommend focusing on patients' quality of life. SDMs were generally reluctant to accept death, whereas physicians found prolonging life at all costs to be morally distressing. The CCB did not interpret appeals to "do everything" legally but followed existing laws by deferring to patients' prior wishes whenever known, or to concepts of "best interests" when not. The CCB generally recommended against life-prolonging measures in these cases (26/41, 63%), focusing on patients' "well-being" and "best interests." In this unique sample of cases involving conflict surrounding resuscitation and end-of-life care, references to "do everything" highlighted conflicts over quantity versus quality of life. These appeals were associated with signs of cognitive distress on the behalf of SDMs who were facing the prospect of a patient's death, whereas physicians identified moral distress related to the prolongation of patients' suffering through their use of life-sustaining interventions. This divergence in perspectives on death versus suffering was consistently the locus of conflict. These findings support the importance of tools such as the Serious Illness Conversation Guide that can be used by physicians to direct conversations on the patients' goals, wishes, trade-offs, and to recommend a treatment plan that may include palliative care. Not applicable.
Sections du résumé
BACKGROUND
In end-of-life situations, the phrase "do everything" is sometimes invoked by physicians, patients, or substitute decision-makers (SDM), though its meaning is ambiguous. We examined instances of the phrase "do everything" in the archive of the Ontario Consent and Capacity Board (CCB) in Canada, a tribunal with judicial authority to adjudicate physician-patient conflicts in order to explore its potential meanings.
METHODS
We systematically searched the CCB's online public archive from its inception to 2018 for any references to "do everything" in the context of critical care medicine and end-of-life care. Two independent assessors reviewed decisions, collected characteristics, and identified key themes.
RESULTS
Of 598 cases in the archive, 41 referred to "do everything" in end-of-life situations. The phrase was overwhelmingly invoked by SDMs (38/41, 93%), typically to advocate for life-prolonging measures that contradicted physician advice. Physicians generally related "doing everything" to describe the interventions they had already performed (3/41, 7%), using it to recommend focusing on patients' quality of life. SDMs were generally reluctant to accept death, whereas physicians found prolonging life at all costs to be morally distressing. The CCB did not interpret appeals to "do everything" legally but followed existing laws by deferring to patients' prior wishes whenever known, or to concepts of "best interests" when not. The CCB generally recommended against life-prolonging measures in these cases (26/41, 63%), focusing on patients' "well-being" and "best interests."
CONCLUSIONS
In this unique sample of cases involving conflict surrounding resuscitation and end-of-life care, references to "do everything" highlighted conflicts over quantity versus quality of life. These appeals were associated with signs of cognitive distress on the behalf of SDMs who were facing the prospect of a patient's death, whereas physicians identified moral distress related to the prolongation of patients' suffering through their use of life-sustaining interventions. This divergence in perspectives on death versus suffering was consistently the locus of conflict. These findings support the importance of tools such as the Serious Illness Conversation Guide that can be used by physicians to direct conversations on the patients' goals, wishes, trade-offs, and to recommend a treatment plan that may include palliative care.
TRIAL REGISTRATION
Not applicable.
Identifiants
pubmed: 35761229
doi: 10.1186/s12910-022-00796-7
pii: 10.1186/s12910-022-00796-7
pmc: PMC9237977
doi:
Types de publication
Journal Article
Systematic Review
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
66Informations de copyright
© 2022. The Author(s).
Références
CMAJ. 2020 Apr 14;192(15):E400-E404
pubmed: 32234725
Crit Care Explor. 2019 Oct 14;1(10):e0052
pubmed: 32166233
Arch Pediatr Adolesc Med. 2012 Aug;166(8):694-5
pubmed: 22869401
J Gen Intern Med. 2016 Jan;31(1):93-9
pubmed: 26391029
J Gen Intern Med. 2012 Dec;27(12):1657-65
pubmed: 23011253
Am J Hosp Palliat Care. 2009 Oct-Nov;26(5):376-83
pubmed: 19571324
Hastings Cent Rep. 2019 Jul;49(4):3
pubmed: 31429958
PLoS One. 2020 Oct 22;15(10):e0238842
pubmed: 33091015
J Crit Care. 2010 Mar;25(1):171.e1-7
pubmed: 19781897
J Hosp Med. 2006 Jul;1(4):231-40
pubmed: 17219504
J Crit Care. 2021 Apr;62:185-189
pubmed: 33421686
J Crit Care. 2013 Feb;28(1):22-7
pubmed: 23228726
Proc (Bayl Univ Med Cent). 2011 Jul;24(3):227-35
pubmed: 21738297
J Palliat Med. 2016 Jan;19(1):112-3
pubmed: 26651524
BMJ Open. 2015 Oct 06;5(10):e009032
pubmed: 26443662
J Gen Intern Med. 2001 May;16(5):283-9
pubmed: 11359545
N Engl J Med. 2012 Jul 5;367(1):8-9
pubmed: 22762313
Intensive Care Med. 2015 Sep;41(9):1572-85
pubmed: 25904183
J Palliat Med. 2019 Jul;22(7):773-781
pubmed: 30724693
J Crit Care. 2019 Jun;51:149-155
pubmed: 30825789
Ann Intensive Care. 2020 Jun 17;10(1):84
pubmed: 32556826
ATS Sch. 2020 Mar 18;1(2):119-133
pubmed: 33870276
Resuscitation. 2015 Nov;96:148-50
pubmed: 26296584
Ann Intern Med. 2005 Nov 15;143(10):744-8
pubmed: 16287796
Clin Invest Med. 2010 Aug 01;33(4):E240-53
pubmed: 20691142