Competing and conflicting interests in the care of critically ill patients

Abstract

Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care.

End-of-Life Care Decision-Making in Stroke

“…Potential biases exist for both clinicians and surrogates collaborating to make shared EOL decisions. Towards recommending what (if any) additional treatments to pursue in stroke patients, a clinician may be influenced, for instance, by a desire to avoid personal or legal accusations by families of patients ( 78 ) in addition to patient factors ( 7 , 20 ). The clinician's prior experiences also affect these decisions; for instance, clinicians with experience in rehabilitation medicine tend to suggest continuation of life-sustaining therapy, perhaps due to a tendency to make positive prognoses ( 79 ).…”

Constructive conflicts of interest: an alternative perspective from industry?

“…All this will "influence" my decision and again nothing is wrong with that. But getting sponsorship from one of those competing companies to support my research will consciously or subconsciously "favour" that company's ventilator through the tender process and this is not acceptable [1][2][3]. Let's assume, however, that by accepting the sponsorship and being able to do the research, it ends up with positive results changing the practices for the patient's benefit.…”

“…Considering that (1) "conflict" is everywhere, between and within individuals, and sometimes has beneficial outputs when such conflicts are constructive; (2) having more than one interest as reported by Turnbull and coworkers [3], and which need to be prioritized during the decision process is very trivial; (3) "influence" is part of human relationships, from childhood where parents are influencers to the adulthood where teachers, colleagues, and leaders are influencing our attitudes and decisions, it finally appears that the problem with COI is not about the "conflict", not about the "interest" and not about "influence" but more about "how to influence" the decision. Influencing a decision-maker by providing personal and private advantages, including small gifts, and meals is definitely not acceptable.…”

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

“…Moreover, medical teams, frequently inexperienced in appropriate management of difficult social or end-of-life situations, promote physician-driven decisions [ 237 , 238 ]. Furthermore, publicly reported quality metrics such as 30-day mortality after general cardiothoracic surgery and 1-year mortality after transplantation can be at odds with patient/family goals [ 239 , 240 , 241 ]. Finally, timing of therapy cessation, defining “futility”, and withdrawal of care while on extensive mechanical support can also be encountered.…”