The concept of a surrogate is ill adapted to intensive care: Criteria for recognizing a reference person

PurposeWe investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation.Materials and methodsMulticentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents’ practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission.ResultsIn total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient’s stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient’s medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework.ConclusionThis study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient’s individual characteristics.

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“…All questionnaires were anonymous. This methodology has previously been described elsewhere [ 17 , 19 ].…”

Section: Methodsmentioning

confidence: 99%

Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices

et al. 2018

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“…Indeed, choosing the spouse, which is often the default position, may not be the most suitable choice in the patient's view (28,29). Several characteristics among the persons attending the patient may help the physicians and ICU staff to identify the most suitable surrogate, such as knowledge of the patient's wishes, the nature of their bond with the patient, and an adequate level of understanding (30).…”

Section: Physician Obtains and Documents Patient's Nonoppositionmentioning

confidence: 99%

Ethical challenges involved in obtaining consent for research from patients hospitalized in the intensive care unit

Ecarnot¹,

Quenot²,

Besch³

et al. 2017

Ann. Transl. Med.

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Clinical research remains a vital contributor to medical knowledge, and is an established and integral part of the practice of medicine worldwide. Respect for patient autonomy and ethical principles dictate that informed consent must be obtained from subjects before they can be enrolled into clinical research, yet these conditions may be difficult to apply in real practice in the intensive care unit (ICU).A number of factors serve to complexify the consent process in critically ill patients, notably decisional incapacity of the patient due to illness or sedation. Obtaining consent for research from a designated proxy or family member, commonly termed a "surrogate decision maker" (SDM) may be difficult, since SDMs dealing with the emotional, psychological and logistic impact of a sudden hospitalisation of their lovedone are not always receptive to the idea of research or emotionally equipped to reflect rationally on the opportunities being proposed to them. In addition, time constraints and workload pressures on the attending physician may render consent opportunities unfeasible, and the resulting loss of eligible patients could represent a bias in clinical trials, or limit the generalizability of their results. Alternative procedures such as deferred or waived consent have been used in the past and may be suitable alternatives in certain conditions, provided appropriate approval from institutional review boards (IRBs) can be obtained, in accordance with existing legislation. Some of the main questions inherent to the conduct of clinical research in critically ill patients are discussed in this review.

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“…Often, the problem is that there is not one spokesperson from the family, but rather a "spokes group" (30). A recent article by Rigaud et al (31) showed that in the ICU, caregivers use simple criteria to identify the most suitable surrogate. These criteria include knowledge of the patient's wishes, an emotional bond with the patient, adequate understanding of the clinical history, and designation as a surrogate prior to admission.…”

Section: How Is the Collegial Process Initiated?mentioning

confidence: 99%

What are the ethical aspects surrounding the collegial decisional process in limiting and withdrawing treatment in intensive care?

Quenot¹,

Ecarnot²,

Meunier-Beillard³

et al. 2017

Ann. Transl. Med.

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The decision to limit or withdraw life-support treatment is an integral part of the job of a physician working in the intensive care unit, and of the approach to care. However, this decision is influenced by a number of factors. It is widely accepted that a medical decision that will ultimate lead to end-of-life in the intensive care unit (ICU) must be shared between all those involved in the care process, and should give precedence to the patient's wishes (either directly expressed by the patient or in written form, such as advance directives), and taking into account the opinion of the patient's family, including the surrogate if the patient is no longer capable of expressing themselves. A number of questions still remain unanswered regarding how decisions to limit or withdraw treatment are taken in daily practice, especially when this decision can be anticipated. We discuss here the collegial procedure for decision-making, in particular in the context of recent French legislation on end-of-life issues. We describe how collegial decision-making procedures should be carried out, and what points are covered in shared discussions regarding decisions to limit or withdraw life-sustaining therapies.

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The concept of a surrogate is ill adapted to intensive care: Criteria for recognizing a reference person

Cited by 12 publications

References 8 publications

Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices

Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices

Ethical challenges involved in obtaining consent for research from patients hospitalized in the intensive care unit

What are the ethical aspects surrounding the collegial decisional process in limiting and withdrawing treatment in intensive care?

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