Ethics Section

Separate thread for Ethics Section members to share articles related to the 'medical futility' topic. Feel free to share any article(s) you think will be appreciated by SCCM colleagues! (Adult + Pediatric)

Prior SCCM Publications:

1.      Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med. 1997 May;25(5):887-91. doi: 10.1097/00003246-199705000-00028. PMID: 9187612.

2.      Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH, Curtis JR, Ford DW, Osborne M, Misak C, Au DH, Azoulay E, Brody B, Fahy BG, Hall JB, Kesecioglu J, Kon AA, Lindell KO, White DB; American Thoracic Society ad hoc Committee on Futile and Potentially Inappropriate Treatment; American Thoracic Society; American Association for Critical Care Nurses; American College of Chest Physicians; European Society for Intensive Care Medicine; Society of Critical Care. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med. 2015 Jun 1;191(11):1318-30. doi: 10.1164/rccm.201505-0924ST. PMID: 25978438.

3.       Kon AA, Shepard EK, Sederstrom NO, Swoboda SM, Marshall MF, Birriel B, Rincom F. Special Article: Defining Potentially Inappropriate Treatment: A Policy Statement from the SCCM Committee on Ethics. Critical Care Medicine 44(9): 1769-1774. September, 2016. IF 6.312

Couple of other publications by members of the writing workgroup (Douglas White MD, Thaddeus Pope JD) that are worth reading: 

1) 'How Seeking Transfer Often Fails to Help Define Medically Inappropriate Treatment'

White DB, Pope TM. How Seeking Transfer Often Fails to Help Define Medically Inappropriate Treatment. Hastings Cent Rep. 2024 Mar;54(2):2. doi: 10.1002/hast.1572. PMID: 38639166.

i) "if potential receiving hospitals answer that they will not accept a patient in transfer, they should be required to provide their reasons."

ii) "if a potential receiving hospital responds that they will not accept the patient and they do not believe that the requested treatments violate community standards, not only
should this evidence be documented in the patient's medical record, but also the physicians and ethics committee at the treating hospital should reexamine the ethics of the case in light of this new information."

2) White DB, Pope TM. The courts, futility, and the ends of medicine. JAMA. 2012 Jan 11;307(2):151-2. doi: 10.1001/jama.2011.1990. PMID: 22235083; PMCID: PMC3530837.

"Patients have an interest in receiving care consistent with their values. Physicians have an interest in not being compelled to act against their beliefs about how
to best respect human dignity near life's end. Society has important interests in protecting individual rights and ensuring the fair allocation of scarce medical resources. When the interests of each party are correctly understood, it is clear that such decisions are not purely "medical" decisions; thus, unilateral clinician decision making is problematic.
Courts have special expertise to adjudicate between parties in the face of conflicts about fundamental interests. Courts fulfill this social role in part by ensuring a fair process of decision making."

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Preeti R. John MD, MPH, FACS, FCCM, HEC-C
Surgeon, Intensivist, Certified Healthcare Ethics Consultant,
Veterans Affairs Maryland Health Care System,
Clinical Associate Professor, Dept. of Surgery,
University of Maryland School of Medicine,
Baltimore, MD
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Dr. Lisa  Schlitzkus asked about the 1997 SCCM Consensus statement - I have it (accessed from my institutional library links) tried posting it here, but the "attach" link/button below does not seem to work. . If anyone else has success in attaching a link please post it! Otherwise I will request assistance from one of the SCCM staff partners! Thanks

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Preeti R. John MD, MPH, FACS, FCCM, HEC-C
Surgeon, Intensivist, Certified Healthcare Ethics Consultant,
Veterans Affairs Maryland Health Care System,
Clinical Associate Professor, Dept. of Surgery,
University of Maryland School of Medicine,
Baltimore, MD
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A topic that has come up in our discussions regarding the medical futility debate:

The 2024 HHS Office for Civil Rights rule on disability nondiscrimination in medical treatment and how it bears on quality-of-life judgments underlying claims of medical inappropriateness:

https://www.hhs.gov/civil-rights/for-individuals/disability/section-504-rehabilitation-act-of-1973/ocr-detailed-504-fact-sheet/index.html

"The Department also recognizes the importance of medical professional expertise and the role that professional judgment plays in medical treatment decisions. Accordingly, the rule acknowledges that treatment can be denied if the recipient has a legitimate, nondiscriminatory reason for denying or limiting treatment or the recipient has reasonably determined, based on current medical knowledge or the best available objective evidence, that such medical treatment is not clinically appropriate for a particular individual.

For example, it would not violate Section 504 if a recipient declined to provide chemotherapy to a patient with a disability based on a judgment that it would not extend the patient's life or mitigate the symptoms of the patient's cancer. Nor would it violate the Department's rule where a recipient determined that a patient with a disability would be exceedingly unlikely to survive cardiac surgery and decides the surgery is not a medically appropriate treatment. In contrast, it would violate Section 504 to deny a patient access to lifesaving treatment due to a belief that the patient would be better off dead because of a physician's perception of their quality of life or because of a belief they would constitute a burden on others.

Section 504 recognizes the importance of a medical professional providing information regarding the implications of different courses of treatment, based on current medical knowledge or the best available objective evidence, to an individual with a disability or their authorized representative. The ability of a person with a disability to understand the available options and to make an informed decision depends in part on the expertise and candor of the treating professional.

However, Section 504 prohibits discrimination in seeking consent to provide, withdraw or withhold treatment. Examples of such discrimination may include applying unique pressure to a person with a disability to agree to the treating professional's position or conditioning access to a particular treatment for a person with a disability on agreeing to a particular advanced care planning decision the recipient would not require for a similarly situated nondisabled patient."

Unilateral decisions about provision / withdrawal of life sustaining treatments are problematic, and appropriate documentation should reflect physiologic parameters and not quality of life judgements.

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Preeti R. John MD, MPH, FACS, FCCM, HEC-C
Surgeon, Intensivist, Certified Healthcare Ethics Consultant,
Veterans Affairs Maryland Health Care System,
Clinical Associate Professor, Dept. of Surgery,
University of Maryland School of Medicine,
Baltimore, MD
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