Ethics of emergency bedside medicineBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l427 (Published 29 January 2019) Cite this as: BMJ 2019;364:l427
All rapid responses
I read Mr Sokol's opinion piece with interest.
He detailed an encounter with the ICU clinicians when the family of a patient who had suffered multi-organ failure and had been supported in hospital critical care unit on a ventilator for 2 months, with no apparent evidence of any progression.
There is a general agreement that neither the clinicians nor the patient and family want treatment in the event of an irreversible and unsurvivable deterioration; they all did not believe that life should be sustained at all costs.
The surprising aspect of it is that it is clear that the conflict between the stakeholders in this clinical care is the somewhat nebulous ideal of "doing everything done unless the situation wasn’t survivable"; Mr Sokol despite his expertise in the medico-legal arena did not appear to recognise this nor specify this as the crux of the matter.
For the clinicians, I would expect that the state of being on the ventilator for 2 months with no foreseeable progression to weaning off the ventilator meant that the situation wasn't survivable for him to go without ventilator to leave to hospital to go home. This would have been confirmed by past unit experience and evidence base; although nothing is 100% certain, they do not hold the view that a very low probability of surviving this condition (to walk out of the hospital in the end) will appropriate for distributive (social) justice for the greater good.
For the family (and perhaps the patient, since Mr Sokol cannot be certain the family represents his own views), they "are worried that the medical team will give up on their father too soon and not allow him a proper chance to pull through". Mr Sokol obviously did not offer judgement, despite his experience, if that 2 months was "a proper chance" for any reasonable person or not. He did not appear to seek confirmation with the family how long a patient, with serious life-changing comorbidities in addition to being on a ventilator, should be given that would be consistent with a "proper chance". Neither did he ask for the clinicians' opinion on anyone with serious comorbidities who still requires a ventilator after 2 months, what are the chances of walk-out-of-hospital survivability.
Granted that he is acting as a advocate to represent the views and interests of the patient's family (and maybe the patient himself), he is entirely justified to limit his action to what the family allows him to do.
However in presenting this story in the BMJ, he continue to represent the family's view without further effort to balance the views than the lip-service he paid acknowledging the clinicians' effort to reconcile with the family's ideal. The irony is that I suspect the clinicians' view involving distributive justice will remain in direct conflict with the family's unfounded (and unchallenged by Mr Sokol) faith and confidence in the certainty that the patient will survive his current state of health (or illness). If there is any acknowledgment by the family (and Mr Sokol) the clinicians' concerns about fear of overtreatment, it is in the context of further deterioration, not the situation of uncertainty of prolonged ventilation.
This massive gap in perception may represent a serious communication failure on both the clinicians and Mr Sokol, but we may never know for sure, since Mr Sokol is the narrator of the story and is not immune to being blindsided from what he chose to see and hear.
Competing interests: No competing interests