Making Medical Treatment Decisions for Unrepresented Patients in the ICU: An Official American Thoracic Society/American Geriatrics Society Policy Statement

201(10) American Journal of Respiratory & Critical Care Medicine 1182-1192 (2020) https://doi.org/10.1164/rccm.202003-0512ST

Posted: 23 Feb 2021

See all articles by Thaddeus Mason Pope

Thaddeus Mason Pope

Mitchell Hamline School of Law; Queensland University of Technology - Australian Health Law Research Center; Saint Georges University; Alden March Bioethics Institute

Douglas White

University of Pittsburgh

Joshua Bennett

University of North Carolina (UNC) at Chapel Hill

Shannon Carson

University of North Carolina (UNC) at Chapel Hill

Lynette Cederquist

University of California, San Diego (UCSD)

Andrew Cohen

Yale University

Erin S. DeMartino

University of Chicago - MacLean Center for Clinical Medical Ethics; Mayo Clinic - Division of Pulmonary and Critical Care

David Godfrey

affiliation not provided to SSRN

Paula Goodman-Crews

Kaiser Permanente

Marshall B. Kapp

Florida State University - College of Law and College of Medicine

Bernard Lo

Independent

David Magnus

Stanford University - Stanford Center for Biomedical Ethics (SCBE)

Lynn Reinke

University of Washington

Jamie Shirley

University of Washington

Mark Siegel

Department of Internal Medicine (Pulmonary, Critical Care & Sleep Medicine), Yale School of Medicine

Renee Stapleton

University of Vermont

Rebecca Sudore

University of California, San Francisco (UCSF)

Anita J. Tarzian

University of Maryland Francis King Carey School of Law

J. Daryl Thornton

Case Western Reserve University

Mark R. Wicclair

West Virginia University - Department of Philosophy; University of Pittsburgh - Department of Medicine & Center for Bioethics and Health Law

Eric Widera

University of California, San Francisco (UCSF)

Date Written: December 7, 2020

Abstract

Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as “unrepresented.” There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice. Purpose and Objectives: This multi-society statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting.

Methods: An inter-professional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law.

Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse inter-professional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient’s preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight.

Conclusions: This multi-society statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.

Keywords: substituted judgment; surrogate; unrepresented; adult orphan; patient without advocate

JEL Classification: I18, I28, K32

Suggested Citation

Pope, Thaddeus Mason and White, Douglas and Bennett, Joshua and Carson, Shannon and Cederquist, Lynette and Cohen, Andrew and DeMartino, Erin S. and Godfrey, David and Goodman-Crews, Paula and Kapp, Marshall and Lo, Bernard and Magnus, David and Reinke, Lynn and Shirley, Jamie and Siegel, Mark and Stapleton, Renee and Sudore, Rebecca and Tarzian, Anita J. and Thornton, J. Daryl and Wicclair, Mark R. and Widera, Eric, Making Medical Treatment Decisions for Unrepresented Patients in the ICU: An Official American Thoracic Society/American Geriatrics Society Policy Statement (December 7, 2020). 201(10) American Journal of Respiratory & Critical Care Medicine 1182-1192 (2020) https://doi.org/10.1164/rccm.202003-0512ST, Available at SSRN: https://ssrn.com/abstract=3743848

Thaddeus Mason Pope (Contact Author)

Mitchell Hamline School of Law ( email )

875 Summit Avenue
Room 320
Saint Paul, MN 55105
United States
651-695-7661 (Phone)

HOME PAGE: http://www.thaddeuspope.com

Queensland University of Technology - Australian Health Law Research Center ( email )

2 George Street
Brisbane, Queensland 4000
Australia

Saint Georges University ( email )

West Indies
Grenada

HOME PAGE: http://www.thaddeuspope.com

Alden March Bioethics Institute ( email )

47 New Scotland Ave
MC 153
Albany, NY 12208
United States

HOME PAGE: http://www.thaddeuspope.com

Douglas White

University of Pittsburgh ( email )

135 N Bellefield Ave
Pittsburgh, PA 15260
United States

Joshua Bennett

University of North Carolina (UNC) at Chapel Hill

102 Ridge Road
Chapel Hill, NC NC 27514
United States

Shannon Carson

University of North Carolina (UNC) at Chapel Hill ( email )

102 Ridge Road
Chapel Hill, NC NC 27514
United States

Lynette Cederquist

University of California, San Diego (UCSD) ( email )

9500 Gilman Drive
Mail Code 0502
La Jolla, CA 92093-0112
United States

Andrew Cohen

Yale University ( email )

New Haven, CT 06520
United States

Erin S. DeMartino

University of Chicago - MacLean Center for Clinical Medical Ethics

5841 S Maryland Ave
Chicago, IL 60637-1470
United States

Mayo Clinic - Division of Pulmonary and Critical Care

Rochester, MN
United States

David Godfrey

affiliation not provided to SSRN

Paula Goodman-Crews

Kaiser Permanente ( email )

San Diego, CA

Marshall Kapp

Florida State University - College of Law and College of Medicine ( email )

625 Eagle View Circle
Tallahassee, FL 32311
United States
618-534-1022 (Phone)

Bernard Lo

Independent ( email )

David Magnus

Stanford University - Stanford Center for Biomedical Ethics (SCBE)

CA
United States

Lynn Reinke

University of Washington ( email )

Seattle, WA 98195
United States

Jamie Shirley

University of Washington ( email )

Seattle, WA 98195
United States

Mark Siegel

Department of Internal Medicine (Pulmonary, Critical Care & Sleep Medicine), Yale School of Medicine ( email )

New Haven, CT 06520-8034
United States

Renee Stapleton

University of Vermont ( email )

212 Kalkin Hall
Burlington, VT 05405-0158
United States

Rebecca Sudore

University of California, San Francisco (UCSF) ( email )

Third Avenue and Parnassus
San Francisco, CA 94143
United States

Anita J. Tarzian

University of Maryland Francis King Carey School of Law ( email )

500 West Baltimore Street
Baltimore, MD 21201-1786
United States

J. Daryl Thornton

Case Western Reserve University ( email )

10900 Euclid Ave.
Cleveland, OH 44106
United States

Mark R. Wicclair

West Virginia University - Department of Philosophy ( email )

Morgantown, WV 26506
United States
304-293-3611 (Phone)

University of Pittsburgh - Department of Medicine & Center for Bioethics and Health Law ( email )

3708 Fifth Avenue
Medical Arts Building, Suite 300
Pittsburgh, PA 15260
United States

HOME PAGE: http://www.pitt.edu/~bioethic/facWicclair.htm

Eric Widera

University of California, San Francisco (UCSF) ( email )

Third Avenue and Parnassus
San Francisco, CA 94143
United States

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