Decision Making Approaches Used to Limit Potentially Non-Beneficial Life-Sustaining Interventions Explored on GeriPal Podcast

The complex and often ethically fraught decisions surrounding the limitation of potentially non-beneficial life-sustaining treatments were the central focus of a recent episode of the GeriPal Podcast. Hosted by Eric Widera and Alex Smith, the discussion featured cardiothoracic anesthesiologist and critical care physician Jason Batten from UCLA, along with hospitalist, sociologist, and ethicist Liz Dzeng from UCSF, and hospitalist and researcher Teva Brender, also from UCSF. The conversation delved into a JAMA Network Open publication titled "Decision Making Approaches Used to Limit Potentially Non Beneficial Life Prolonging Interventions," which examined the real-world practices of clinicians when faced with situations where treatments may offer little to no benefit to patients.

The Core Dilemma: Balancing Medical Intervention with Patient Well-being

At its heart, the discussion revolved around a critical tension in modern medicine: the drive to preserve life versus the ethical imperative to avoid prolonging suffering or providing treatments that do not align with a patient’s ultimate goals and values. The podcast episode highlighted a significant gap between established ethical guidelines and the practical realities faced by clinicians in the intensive care unit (ICU) and other high-acuity settings.

"We’re talking about how we limit potentially non-beneficial life-sustaining treatments," Eric Widera stated at the outset of the discussion, framing the episode’s core theme. This issue, he explained, is particularly pertinent in critical care, where advanced technologies can prolong biological life even when the prospect of meaningful recovery or improved quality of life is minimal.

The JAMA Network Open paper, co-authored by Batten and Dzeng, sought to understand the decision-making frameworks clinicians actually employ in these challenging scenarios, moving beyond theoretical ethical principles to observe actual practices.

The Genesis of the Research: From "Slow Codes" to Systematic Inquiry

The impetus for the podcast episode and the underlying research stemmed from a prior GeriPal Podcast discussion on "slow codes" – a term that refers to the practice of performing cardiopulmonary resuscitation (CPR) in a manner that is less aggressive and less likely to result in successful resuscitation, often done when a full resuscitation is deemed futile. Teva Brender, who suggested the topic for the podcast, explained his motivation: "I was inspired by your podcast on slow codes and the ethics of doing a slow code, and there were great arguments for and against. And I thought, hey, I know a couple people who’ve done some great research on this sort of thing and who have shown the different decision making frameworks that clinicians use in the real world."

Brender elaborated that the research aimed to explore how clinicians on the ground, rather than just adhering to abstract ethical principles, navigate these complex situations. He pointed to examples like offering dialysis to a patient where the outcome is highly uncertain and unlikely to be beneficial, raising the question of whether to even introduce such an option to a family. This highlights the pragmatic challenges faced by clinicians who must balance providing all possible options with avoiding unnecessary distress or false hope.

Jason Batten shared his own long-standing interest in this area, stemming from his background as a clinical ethicist. "I just remember one of my central questions after that period was, when do doctors get to say no?" Batten recalled. He described witnessing "absolutely bananas. ICU goals of care conversations" where treatments felt increasingly non-beneficial, prompting his curiosity about the decision-making processes that deviate from established protocols.

Liz Dzeng’s motivation was rooted in her residency experience at an institution in New York with state laws that influenced end-of-life care decisions. She expressed a long-standing interest in "how policies shape how we make decisions and the culture of an institution." She recalled a particularly challenging situation involving "informed dissent," a concept that generated significant discussion and tension among her team, underscoring the nuanced and often contentious nature of these ethical discussions.

The Qualitative Approach: Uncovering Nuance and Lived Experience

The research underpinning the JAMA Network Open article employed a qualitative methodology, involving in-depth interviews with a range of healthcare professionals, including physicians, nurses, staff, administrators, and healthcare leaders across three West Coast institutions with varying levels of end-of-life care intensity. This approach, Liz Dzeng explained, allowed for a deep exploration of "why there may be differences in the institutional cultures, policies, structures that influence the intensity of end of life care at those institutions."

Jason Batten emphasized the value of qualitative data in capturing the "lived reality on the ground." He contrasted this with quantitative studies that often focus on structured goals-of-care conversations, arguing that "some of the most important interactions happen, you know, out in the hallway when you’re kind of informally walking through a room checking somebody’s vitals who’s unstable." This ethnographic approach, he contended, is crucial for understanding what clinicians actually do, beyond what they say they do.

Liz Dzeng further highlighted the richness of qualitative research, noting its ability to uncover not only what is happening but also "what people are thinking about it and how people’s perspectives on what they’re seeing influences each other, influences the institution, how that sort of in aggregate then influences the culture." This depth of understanding, she argued, is difficult to achieve through quantitative methods alone.

Frameworks for Decision Making: Recommended vs. Alternate Approaches

The study identified and categorized various decision-making approaches used by clinicians when limiting potentially non-beneficial life-sustaining treatments. Jason Batten outlined an analytic framework that distinguished between "recommended approaches" and "alternate approaches."

Recommended Approaches: These align with established ethical and clinical guidelines and include:

1. Shared Decision-Making: This involves a collaborative process where patients and families agree with the clinician’s recommendation to limit or withdraw life-sustaining treatments. The goal is to reach a consensus.
2. Institutional Policy/Futility Process: When shared decision-making fails, and a treatment is deemed to have a "zero percent probability of achieving its intended outcome" (i.e., physiologic futility), guidelines allow for the withholding or withdrawal of that treatment. Examples cited, though extreme, included administering antifungals for a myocardial infarction or performing CPR on a corpse. More practically, this involves invoking institutional policies for medically ineffective care or utility processes when disagreements arise and physiologic futility isn’t clearly met. These processes typically involve broader institutional review beyond the immediate clinical team.

Alternate Approaches: These are practices observed in real-world clinical settings that do not strictly adhere to the recommended approaches. The study identified several categories:

1. Stating a Plan to Limit Interventions: This approach involves the physician informing the patient or family of a decision to stop interventions and transition to comfort care without necessarily providing an opportunity for objection or presenting alternatives. The paper noted that this sometimes deviates from the original concept of "informed dissent," which implies maintaining choice and shared decision-making principles.
2. Not Offering Interventions: This involves a deliberate decision by the clinician not to propose certain treatments, even if they might be medically indicated or requested by the family. This can include consciously deciding not to involve a specialist who might offer a particular intervention.
3. Not Mentioning Interventions: This is perhaps the most subtle approach, where an intervention is not brought up in discussions with the patient or family. This can occur through informal agreements within the healthcare team to avoid mentioning certain treatments, effectively removing them from consideration without an explicit refusal. This often happens in hallway conversations and is not documented.

Batten emphasized that the study’s goal was not to label these approaches as "good" or "bad" but rather to understand their prevalence and the ethical considerations they raise. He acknowledged that "clinicians often don’t know exactly what’s going on in the other party’s head" during these complex conversations, underscoring the difficulty in definitively categorizing every interaction.

The "Bridge to Nowhere" Phenomenon and the Limits of Futility

A significant point of discussion was the concept of "bridge treatments" – interventions like ECMO (extracorporeal membrane oxygenation) or continuous renal replacement therapy (CRRT) that are intended to sustain a patient temporarily while they recover. However, the conversation highlighted the increasing reality of "bridges to nowhere," where these interventions prolong life in an ICU setting without a clear path to recovery or discharge.

Eric Widera posed the question: "When we don’t view them as bridges to anywhere… what are we doing here?" This raises the ethical quandary of continuing interventions that, while not strictly futile in prolonging biological life, do not contribute to a patient’s overall well-being or align with their goals. Jason Batten, who deals with ECMO frequently, noted the stark contrast between how such interventions are approached versus others. He described situations where physicians might refuse to offer ECMO outright, even against the primary team’s or family’s wishes, whereas intubation for a desaturating patient, even with perceived futility, is often still performed. This suggests a degree of specialization and cultural variation in decision-making for different interventions.

Liz Dzeng added that the "technological imperative" in American medicine, coupled with the constant advancement of technology, means that what is considered experimental today could become standard of care tomorrow. This ongoing evolution necessitates a continuous re-evaluation of ethical frameworks and guidelines.

The Role of Moral Distress and Institutional Culture

Teva Brender’s previous work from the same dataset explored moral distress among clinicians. He found that moral distress was exacerbated by the "default trajectory towards high intensity treatments" and conflicts with families or other clinicians. Conversely, a supportive palliative care culture helped mitigate this distress. He also noted the influence of institutional reputation, where prominent academic medical centers create an expectation of intensive treatments, further complicating end-of-life decisions.

Liz Dzeng reiterated the importance of understanding the broader societal and institutional context. She stated, "We operate in a default of high intensity treatments near the end of life… And like even that alone, that’s not necessarily concordant with what most people want." She also highlighted the "tremendous burden that families face in trying to make decisions," suggesting that presenting a "false choice" of numerous potentially unhelpful options can be harmful.

The variability in how ethics committees and institutional policies are perceived and utilized was also discussed. Eric Widera noted that some ethics committees seem driven by legal concerns, while others are more flexible. This variation, coupled with the perceived burden of navigating these committees, can lead clinicians to employ "workarounds," as Liz Dzeng termed them, to manage these difficult situations.

Implications and Future Directions

The podcast episode and the research underscore several key implications for healthcare providers and institutions:

• Need for Clearer Guidelines: While existing guidelines provide a foundation, the study suggests a need for more nuanced and practical guidance to address the complexities of "non-beneficial" care that doesn’t fit the narrow definition of physiologic futility.
• Enhanced Clinician Training: The research highlights the importance of equipping clinicians with the skills and frameworks to navigate these ethically challenging conversations, emphasizing intentionality in their approach.
• Promoting Transparency and Discussion: The prevalence of "alternate approaches" suggests a disconnect between policy and practice. Greater transparency and open discussion about these practices are needed to ensure ethically sound decision-making.
• Revisiting "Shared Decision-Making": The definition and application of shared decision-making in critical care require careful consideration. The challenge lies in offering meaningful choices without overwhelming patients and families or presenting false options.

Jason Batten’s "magic wand" wish was for clinicians to recognize the ethical uncertainties involved in using alternate approaches and to "think carefully" about whether their actions are truly ethically acceptable and in the best interest of the patient. Liz Dzeng echoed this, urging clinicians to be "intentional about… what approach am I using?" Teva Brender added the importance of being mindful of the family’s perspective and being prepared to pivot strategies during conversations. Alex Smith concluded by emphasizing the need to "revisit the guidelines" when widespread deviation from them is observed, indicating that practice may be outstripping current policy.

The discussion concluded by acknowledging the deeply "wicked questions" surrounding what constitutes beneficial care and who gets to decide, highlighting the ongoing and evolving nature of ethical discourse in end-of-life care. The research presented offers a crucial step in understanding the real-world landscape of these decisions, providing a foundation for future dialogue and policy development.