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What to do when families disagree about ending life support

From the June 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Ingrid Palmer

PHILADELPHIA—Paul N. Lanken, FACP, faced three shocked relatives when he met with the family of a 42-year-old asthmatic man who arrived in the emergency room after a severe asthma attack and was now in a vegetative state. Initially, family members agreed that they wanted to pursue treatment as long as there was hope. But the patient's wife remembered her husband commenting during an episode of "ER" that he wouldn't want to be kept alive in a vegetative state. This upset his mother and sister, leaving Dr. Lanken, professor of medicine, division of pulmonary, allergy and critical care medicine at the Hospital of the University of Pennsylvania, to grapple with a difficult situation.

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The scenario, which Dr. Lanken described at the Annual Session presentation, "Clinical and Ethical Issues in Ending Life Support in the Intensive Care Unit," illustrates the difficult position in which doctors find themselves when family members consider ending life support. Legal and ethical issues can emerge as estranged families or relatives disagree on what care is appropriate for the patient. In some situations, it may be difficult to simultaneously respect family members' wishes and uphold a patient's right to refuse life-sustaining care.

"When engaged in an ethical dilemma," Dr. Lanken said, "I try to figure out what values and principles are in conflict." Sometimes, he said, conflicts stem from a simple lack of understanding about a patient's pain level or the specifics of different treatment plans. For example, a physician may need to define for the family exactly what "comfort measures" mean.

Dr. Lanken offered the following advice:

  • State your opinion. Openly talk about your experiences and your medical opinion of the patient's condition. Also give your opinion of the patient's chances for survival.

Sometimes, he said, sharing an opinion has more effect than talking about statistics, because the American public does not fully understand or trust probability. Besides giving family members information they need to make a decision, he said, these conversations also help establish trust.

  • Discuss goals. Be sure to talk about the goals of therapy with the family and develop a treatment plan that upholds those goals. Dr. Lanken said that treating the patient's symptoms sometimes helps the family the most. For instance, if a patient who cannot feel anything appears to have trouble breathing, Dr. Lanken said that he may approach the family about administering morphine-like drugs so the patient won't appear to be in distress.

  • Identify a decision-maker. Dr. Lanken suggested working with the family early on to identify a primary decision-maker. It may be necessary to include a nurse, resident, close friends of the patient or a religious advisor in these family meetings.

  • Follow procedures. In cases where family members disagree about treatment and there is no power of attorney or written directive, Dr. Lanken said to follow hospital and legal procedures closely. "Sometimes, the family will never reach a consensus," he said. "But with time, most families will come to some sort of agreement. They just have to take time to process the situation."

  • Send a card. Make a point of sending the family a sympathy card after the patient's death.

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