Process for lack of Consensus on Goals of Treatment at the End of life

In most situations, consensus among patient, family and caregivers about the goals of treatment will occur through a process of good communication and sharing of information. In some situations, however, consensus about the appropriate goals of treatment will not be attained. The following suggestions for addressing a lack of consensus in these matters are guidelines only and are not intended to supersede clinical judgment or individualized patient care. The Department of Bioethics or the Ethics Committee is available for consultation at any time by calling x. 48720.

I.   Lack of consensus may result when health care team members disagree among themselves. In such situations, the following process may be initiated by the attending physician or by another member of the health care team with the agreement and participation of the attending physician:

A) A meeting of the interdisciplinary health care team:

1. Include caregivers involved from the primary service and relevant consult services. Relevant consult services, in addition to medical/surgical and nursing services, may include:

•  Social Work

•  Psychiatry

•  Bioethics

•  Pastoral Care

•  Nutrition Services

•  Other relevant services (e.g., Respiratory Therapy, Pharmacy, etc.)

2. Ensure that caregivers have adequate medical information.

•  Explore and review treatment options

•  Discuss burdens, benefits and treatment alternatives

3. Ensure that beliefs and values of team member are explored.

4. Explore the wishes of the patient as expressed by patient, surrogate and/or advance directive.

5. Explore other relevant issues:

•  Legal

•  Conflicts of interest

•  Social norms of unit/department/Foundation

•  Spiritual and cultural background

B) If the attending physician is not in agreement with having an interdisciplinary meeting, the Bioethics Department may be consulted for assistance in conflict resolution.

C) If the interdisciplinary meeting fails to achieve consensus:

1.  Consider all resources to achieve agreement (e.g., Social Work, Child Life, Psychiatry,

Bioethics, Office of General Counsel, Ombudsman.)

2.  Consider institutional Ethics Committee review.

II.  Lack of consensus about goals of treatment may also result when patients and or family members disagree with the recommendations of the health care team. After assuming that team members have attained consensus, the following process is recommended:

A. Meeting with patient, family, other relevant support persons and health care team:     

1. Ensure that patient and family member have adequate medical information.

•  Explore and review treatment options

•  Discuss burdens, benefits and treatment alternatives

2. Explore wishes of patient as expressed by patient, surrogate and/or advance directive.

3. Ensure that beliefs and values of patient/family members are explored.

•  Beliefs about health care, illness

•  Spiritual beliefs, values

•  Family relationships

4. Ensure that medical information and professional recommendations are shared with patient and family.

5. Identify points of conflict between team and patient/family.

•  Can caregivers verbalize patient/family's position?

•  Can patient/family verbalize patient's medical condition, prognosis, and option?

•  Is the conflict based on a deficit of knowledge?

•  Is the conflict based on a difference of values?

•  Is the conflict based on mistrust?

6. Strategies compromise solutions agreeable to the parties. Examples:

•  Time limit on a particular treatment

•  Second opinion from another physician

•  Continue aggressive treatments except for CPR

•  Palliative Medicine/hospice consultation

•  No further escalation or limited escalation of selected treatments

•  Others?

B.  If parties achieve consensus, proceed with plan.

C. If a consensus of team and patient/family cannot be reached:

1. Reevaluate treatment goals.

2. Communicate changes or lack of change in medical assessment of situation to patient/family.

3.  Consult with ancillary services as necessary and informed patient/family or services (e.g., Social Work, Child Life, Psychiatry, Nutrition Services, General Counsel, Ombudsman, Pastoral Care, and Bioethics.)

D. If consensus is still unattained, initiate case review by Ethics Committee.

E.  In the event of a lack of consensus between patient/family and the health care team, life-sustaining treatment should not be withheld or withdrawn from a patient without the advice of the Office of General Counsel.

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