Futility and Ethics Consultation in Intensive Care

Quick Answer

Medical futility describes clinical situations where interventions cannot achieve meaningful patient goals. It encompasses quantitative futility (treatment has <1% chance of success), qualitative futility (survival with unacceptable quality of life), physiological futility (treatment cannot achieve physiological goal), and normative futility (treatment violates professional norms). Modern discourse prefers "potentially inappropriate treatment" (PIT) to acknowledge the value-laden nature of these judgments. Ethics consultation provides structured support when clinicians and families disagree about treatment goals, reducing ICU length of stay by 2-4 days without increasing mortality (PMID: 12966123). The ANZICS-CORE Statement on Care and Decision-Making at the End of Life provides Australian/NZ guidance emphasizing shared decision-making, cultural safety, and graduated conflict resolution. Australian law recognizes advance care directives and substitute decision-makers but varies by state/territory. Ethical frameworks include principlism (autonomy, beneficence, non-maleficence, justice), virtue ethics (character-based decision-making), and care ethics (relational and contextual focus). Conflict resolution follows a stepwise approach: enhanced communication → ethics consultation → second opinion → time-limited trials → external review → guardianship tribunal.[1,2,3]

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CICM Exam Focus

Second Part Written Exam

Futility and ethics consultation appear frequently in CICM examinations:

Common SAQ Topics

• "Define medical futility and its subtypes. Discuss the concept of potentially inappropriate treatment."
• "Outline the role and process of ethics consultation in the ICU."
• "Describe conflict resolution strategies when family demands treatment the team considers futile."
• "Compare ethical frameworks for end-of-life decision-making in intensive care."
• "Discuss the ANZICS-CORE Statement on end-of-life care in the Australian/NZ context."

Viva Scenarios

• Managing family demand for CPR in a patient the team considers unsurvivable
• Ethics consultation process for a patient with no advance directive and conflicting family views
• Cultural considerations when discussing futility with Indigenous families
• Legal pathways when family and clinical team disagree fundamentally
• Balancing autonomy with professional integrity in cases of requested inappropriate treatment

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Key Points

Definitions

• Medical futility: Treatment that cannot achieve its intended physiological or patient-centered goals
• Quantitative futility: Probability of success is below an acceptably low threshold (traditionally <1%)
• Qualitative futility: Treatment may sustain life but with a quality the patient would consider unacceptable
• Physiological futility: Treatment cannot achieve its physiological aim (e.g., CPR in asystole from exsanguination)
• Normative futility: Treatment conflicts with accepted professional standards and norms
• Potentially inappropriate treatment (PIT): Current preferred terminology acknowledging value-laden nature of "futility"

Ethical Frameworks

• Principlism: Four principles framework (autonomy, beneficence, non-maleficence, justice)
• Virtue ethics: Focus on character and practical wisdom (phronesis) of the clinician
• Care ethics: Emphasis on relationships, context, and responsiveness to vulnerability
• Double effect: Actions with both good and bad effects permissible if good is intended and proportionate
• Proportionality: Treatment burden must be proportionate to expected benefit

Legal Considerations

• Advance care directives: Patient's written treatment preferences; legally binding if valid in jurisdiction
• Substitute decision-maker (SDM): Person authorized to make medical decisions when patient lacks capacity
• Hierarchy varies by state: Generally spouse/partner → adult children → parents → siblings
• Guardianship tribunal: State body that can adjudicate disputed treatment decisions
• Unilateral decisions: Legally and ethically fraught; require ethics consultation and documentation

Ethics Consultation

• Schneiderman RCT (2003): Ethics consultation reduced non-beneficial LST without increasing mortality [PMID: 12966123]
• Functions: Facilitate communication, provide ethical analysis, mediate conflict, make recommendations
• Models: Individual consultant vs committee model; proactive vs reactive consultation
• Outcomes: Reduced LOS, improved family satisfaction, reduced moral distress

ANZICS-CORE

• Statement on Care and Decision-Making at the End of Life: Australian/NZ guidance for ICU practice
• Emphasizes shared decision-making, patient-centered goals, cultural safety
• Graduated conflict resolution: communication → ethics → second opinion → tribunal
• Recommends early palliative care involvement

Indigenous Health

• Aboriginal and Torres Strait Islander: Community-based decision-making, Elder involvement, "on country" dying
• Māori: Whānau-centered decisions, kaumātua (Elder) authority, tikanga practices
• Communication: Aboriginal Health Workers/Liaison Officers, yarning approach, avoid direct death discussion
• Trust issues: Historical trauma, institutional distrust require culturally safe approaches

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Clinical Overview

Definitions of Medical Futility

Medical futility has evolved from a seemingly objective clinical concept to a recognized value-laden judgment that requires careful ethical analysis. Understanding the different types of futility is essential for CICM candidates.

Quantitative Futility

Definition: Treatment has an extremely low probability of achieving its intended goal, typically defined as less than 1% chance of success.

Origin: Schneiderman and colleagues proposed that if a treatment has failed in the last 100 cases, it may be considered quantitatively futile.[4]

Examples:

• CPR in a patient with septic shock, multi-organ failure, and SOFA score >15 (survival rate <1%)
• Mechanical ventilation for end-stage pulmonary fibrosis with no transplant option
• ECMO for refractory cardiogenic shock with irreversible myocardial damage

Criticisms:

• Probability thresholds are arbitrary (why 1% and not 2% or 0.1%?)
• Ignores patient values about what risks are acceptable
• Prognostic uncertainty makes precise probability estimates difficult
• Data from populations may not apply to individuals

Qualitative Futility

Definition: Treatment may achieve its physiological goals but results in a quality of life the patient would find unacceptable.

Key Points:

• Highly subjective and value-dependent
• Must reflect patient's values, not clinician's or family's
• Requires knowledge of patient's prior statements about acceptable QoL
• More controversial than quantitative futility

Examples:

• Continued ventilation for patient in persistent vegetative state
• ICU care for advanced dementia with intercurrent illness when patient previously expressed wishes
• Aggressive resuscitation leading to severe anoxic brain injury

Challenges:

• What constitutes "acceptable" quality of life varies enormously between individuals
• Patients may change their views when actually facing disability
• Surrogates often have difficulty predicting patient preferences accurately
• Cultural and religious factors influence QoL assessments

Physiological Futility

Definition: Treatment cannot achieve its physiological aim, regardless of patient values or preferences.

Key Points:

• Most objective and least controversial form of futility
• Based on scientific/physiological principles
• Generally uncontroversial to withhold
• Rare in practice; most ICU situations involve some chance of success

Examples:

• CPR for patient with documented asystole from exsanguinating hemorrhage
• Dialysis for anuric patient with bilateral nephrectomy (without transplant plan)
• Mechanical ventilation for patient with complete spinal cord transection at C1 who has arrested

Application:

• Clinicians can (and should) decline to provide physiologically futile treatment
• No ethical obligation to offer treatments that cannot work
• Does not require patient/family agreement

Normative Futility

Definition: Treatment conflicts with accepted professional norms and standards, even if technically possible.

Key Points:

• Based on professional ethics and community standards
• May invoke professional integrity
• Can justify refusal even when treatment is technically possible
• Subject to societal and professional consensus

Examples:

• Providing CPR to a patient with valid DNACPR order against family wishes
• Administering lethal medication at family request (euthanasia in non-legal jurisdictions)
• Continuing maximal support indefinitely when clinical team agrees patient cannot benefit

Relevance:

• Supports concept that clinicians are not "vending machines" for medical interventions
• Professional organizations (ATS, ACCP, SCCM, ANZICS) have issued statements supporting this concept
• Requires balance with respect for patient/family autonomy

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Potentially Inappropriate Treatment (PIT)

Evolution of Terminology:

The concept of "medical futility" has been criticized and largely replaced in professional discourse by "potentially inappropriate treatment" (PIT).[5]

Rationale for PIT Terminology:

• Acknowledges that determinations of appropriateness involve value judgments
• Reduces adversarial framing ("futile" can sound dismissive)
• Opens dialogue rather than closing it
• Recognizes uncertainty in prognosis
• Shifts focus from whether treatment "works" to whether it aligns with patient goals

ATS/AACN/ACCP/ESICM/SCCM Policy Statement (2015):

The multi-society policy statement "Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units" provides the definitive framework for managing these situations.[5]

Key Principles:

1. "Potentially inappropriate" acknowledges uncertainty and opens dialogue
2. Process-based approach rather than unilateral determinations
3. Shared decision-making should be attempted first
4. Ethics consultation recommended for persistent disagreements
5. Institutional policies should guide practice
6. Unilateral decisions are last resort after exhaustive process

Process Recommended:

1. Enhanced communication: Multiple family meetings, interdisciplinary approach
2. Ethics consultation: If disagreement persists
3. Second medical opinion: Within or outside institution
4. Institutional review: Ethics committee or policy-based review
5. Transfer opportunity: Allow time for family to arrange transfer to willing provider
6. External review: Guardianship tribunal or court if required

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Ethical Frameworks

Principlism (Beauchamp and Childress)

The four-principles approach remains the most widely used ethical framework in medical decision-making.[6]

Autonomy

Definition: Respect for patients' right to self-determination regarding their medical care.

Application in ICU:

• Most ICU patients lack decision-making capacity
• Autonomy expressed through advance care directives
• Substitute decision-makers should use "substituted judgment" standard
• Patient's values and preferences should guide decisions

Challenges:

• Advance directives often not available or not specific enough
• Surrogates have difficulty predicting patient preferences (accuracy ~70%)
• Cultural variations in emphasis on individual vs family autonomy
• Some argue excessive focus on autonomy neglects clinician expertise

Beneficence

Definition: Duty to act in the patient's best interest.

Application:

• May involve transitioning from curative to comfort-focused care
• Includes timely provision of palliative care
• Requires honest communication about prognosis
• Acting in patient's interests may mean limiting aggressive treatment

Tensions:

• What constitutes "benefit" is partly value-dependent
• Family may perceive benefit differently from clinicians
• Short-term survival vs quality of life trade-offs

Non-Maleficence

Definition: Obligation to avoid harming the patient ("primum non nocere").

Application:

• Core argument for limiting futile/inappropriate treatment
• Ongoing treatment may prolong dying and cause suffering
• Invasive interventions carry inherent harms (pain, loss of dignity)
• Must weigh treatment burden against expected benefit

Principle of Double Effect:

• Medications intended to relieve suffering may hasten death
• Ethically permissible if:
  • Action itself is morally good/neutral
  • Bad effect not intended (though foreseen)
  • Bad effect not means to achieve good effect
  • Good effect proportionate to bad effect

Justice

Definition: Fair distribution of healthcare resources.

Micro-level Application:

• ICU resources (beds, staff, equipment) are finite
• Providing futile treatment consumes resources others could benefit from
• Rarely invoked at bedside but important at policy level

Macro-level Application:

• Healthcare systems must allocate resources fairly
• Pandemic resource allocation highlights justice considerations
• Access to ICU should not depend on socioeconomic status

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Virtue Ethics

Origin: Aristotelian tradition focusing on character and moral virtues.

Core Concept:

• Ethical action flows from virtuous character
• Phronesis (practical wisdom) allows application of virtues to specific situations
• Focus on what a "virtuous clinician" would do

Relevant Virtues for Intensivists:

• Compassion: Emotional attunement to patient/family suffering
• Integrity: Consistency between professional values and actions
• Honesty: Truthful communication even when difficult
• Prudence: Practical wisdom in complex situations
• Courage: Willingness to have difficult conversations
• Humility: Acknowledging uncertainty and limitations

Application to Futility:

• Virtuous clinician balances honesty about prognosis with compassion for family
• Recognizes limits of medical intervention without abandoning patient
• Acts with integrity even when pressured to provide inappropriate treatment
• Uses practical wisdom to navigate cultural and individual differences

Strengths:

• Accounts for the role of character in ethical decision-making
• Recognizes importance of clinical judgment and experience
• Complements rule-based approaches (principlism)

Criticisms:

• May be difficult to adjudicate disagreements about what virtue requires
• Can appear elitist or paternalistic
• Less concrete guidance than rule-based approaches

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Care Ethics (Ethics of Care)

Origin: Feminist philosophy, particularly Carol Gilligan and Nel Noddings.[7]

Core Concepts:

• Moral reasoning is relational and contextual
• Emphasizes responsibility for vulnerable others
• Caring relationships are ethically fundamental
• Rejects abstract universalism in favor of attention to particulars

Key Elements:

• Attentiveness: Recognizing and attending to needs of others
• Responsibility: Taking on responsibility for care
• Competence: Providing adequate care
• Responsiveness: Understanding care recipient's perspective

Application in ICU:

• Focus on family as unit of care, not just patient
• Attention to emotional and relational aspects of decision-making
• Recognition that families need support and time to process
• Emphasis on presence and accompaniment, not just problem-solving

Relevance to Futility Discussions:

• Care ethics encourages empathetic engagement with family
• Values the relationship between clinician and family
• May prioritize process and communication over outcome
• Recognizes that "right answer" may emerge from caring relationship

Strengths:

• Humanizes ethics beyond abstract principles
• Validates emotional aspects of medical decision-making
• Particularly relevant to end-of-life care

Criticisms:

• May not provide clear guidance when conflict persists
• Risk of being too accommodating to unreasonable requests
• Difficulty generalizing beyond particular relationships

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Casuistry (Case-Based Reasoning)

Approach: Ethical analysis through comparison with paradigm cases.

Method:

• Identify morally significant features of the case
• Compare with clear paradigm cases (obvious right/wrong answers)
• Reason by analogy to determine appropriate action
• Relies on accumulated wisdom from similar cases

Application to Futility:

• Compare current case with past cases where consensus was achieved
• Identify features that make current case similar or different
• Draw on institutional and societal precedents

Examples of Paradigm Cases:

• Clear futility: CPR for patient with documented asystole from massive hemorrhage
• Clear non-futility: Treatable infection in otherwise healthy patient
• Gray zone: Multi-organ failure with uncertain prognosis

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Comparative Framework Application

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Legal Considerations

Australian Legal Framework

End-of-life law in Australia is primarily state and territory-based, with no comprehensive federal legislation.[8]

Advance Care Directives

Definition: Written document expressing a person's preferences for future medical treatment when they lack capacity.

Terminology by Jurisdiction:

Key Legal Requirements:

• Person must have had capacity when creating directive
• Directive must be witnessed and/or certified (varies by jurisdiction)
• Directive must be applicable to the current clinical circumstances
• Some jurisdictions require specific forms

Limitations in ICU:

• Many patients do not have advance directives
• Directives may not anticipate the specific clinical situation
• Directives may be vague or use unclear language
• May conflict with current clinical reality
• Cultural groups may not embrace individualistic advance planning

Substitute Decision-Makers

Definition: Person authorized to make medical decisions on behalf of a patient who lacks capacity.

General Hierarchy (varies by jurisdiction):

1. Appointed guardian or attorney under medical/enduring power of attorney
2. Spouse or domestic partner
3. Primary carer (in some jurisdictions)
4. Adult children (may require consensus or eldest)
5. Parents
6. Siblings
7. Other relatives or close friends

Authority:

• SDM should make decisions the patient would have made (substituted judgment)
• If patient's wishes unknown, SDM should act in patient's best interests
• SDM authority may be limited by advance directive
• SDM cannot authorize treatments that are not in patient's interests

State-Specific Legislation:

• Victoria: Medical Treatment Planning and Decisions Act 2016
• NSW: Guardianship Act 1987
• Queensland: Guardianship and Administration Act 2000, Powers of Attorney Act 1998
• SA: Advance Care Directives Act 2013
• WA: Guardianship and Administration Act 1990
• Tasmania: Guardianship and Administration Act 1995
• NT: Advance Personal Planning Act 2013
• ACT: Medical Treatment (Health Directions) Act 2006

Guardianship Tribunals

Function: State and territory bodies that can:

• Review medical treatment decisions
• Appoint guardians for persons without capacity
• Resolve disputes about treatment decisions
• Authorize or prohibit specific treatments

When to Involve:

• No substitute decision-maker available
• Conflict between family members
• Fundamental disagreement between family and clinicians
• Unclear legal authority to proceed

Process:

• Application (by clinician, family member, or interested party)
• Hearing (may be urgent if time-critical)
• Decision (written, may be appealed)

Examples:

• Victoria: Victorian Civil and Administrative Tribunal (VCAT)
• NSW: NSW Civil and Administrative Tribunal (NCAT)
• Queensland: Queensland Civil and Administrative Tribunal (QCAT)

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New Zealand Legal Framework

Protection of Personal and Property Rights Act 1988

• Governs decision-making for persons lacking capacity
• Establishes Welfare Guardianship for medical/personal decisions
• Family Court has jurisdiction

Advance Directives

• Recognized under common law (not statute)
• Must be voluntarily made, informed, and applicable
• Given effect by courts when valid

Key Cases

• Re G [1997]: Established that withdrawal of life support is not unlawful if in patient's best interests
• Auckland Area Health Board v Attorney-General [1993]: Court approved withdrawal of ventilation from patient in persistent vegetative state

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Legal Cases Relevant to Futility (International)

Australia

Northridge v Central Sydney Area Health Service [2000] NSWSC 1241:

• Court upheld hospital's decision not to provide CPR to elderly patient
• Established that doctors not obliged to provide treatment they consider futile

Messiha v South East Health [2004] NSWSC 1061:

• Family sought to compel continued treatment for comatose patient
• Court found doctors entitled to withdraw treatment if not in patient's best interests

United Kingdom

Airedale NHS Trust v Bland [1993]:

• House of Lords approved withdrawal of artificial nutrition and hydration from patient in persistent vegetative state
• Established that withdrawal of futile treatment is not unlawful

R (Burke) v GMC [2005]:

• Clarified that patients cannot demand specific treatments
• Doctors not obliged to provide treatment they consider inappropriate

Charlie Gard (2017) and Alfie Evans (2018):

• High-profile cases of parental requests for continued treatment
• Courts found in favor of hospitals on best interests grounds

United States

Cruzan v Director, Missouri Department of Health (1990):

• US Supreme Court recognized constitutional right to refuse treatment
• Established evidentiary standards for surrogate decisions

Wanglie Case (1991):

• Hospital sought to discontinue ventilator over family objection
• Court upheld family's right to continue treatment
• Illustrates US legal preference for family authority

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Ethics Consultation

Role of Ethics Consultation in ICU

Definition: A process by which individuals or committees with ethics expertise assist clinicians, patients, and families in addressing ethical dilemmas in patient care.[9]

Functions:

1. Case consultation: Address specific ethical questions in individual cases
2. Policy development: Assist in developing institutional ethics policies
3. Education: Provide ethics education to staff, patients, families
4. Support: Reduce moral distress among clinicians

Indications for Ethics Consultation in ICU:

• Disagreement between clinicians and family about treatment goals
• Conflict among family members about decision-making
• Uncertainty about patient's wishes or best interests
• Clinician moral distress about treatment decisions
• Requests for treatments team considers inappropriate
• Complex resource allocation decisions
• End-of-life care planning disputes

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Evidence for Ethics Consultation

Schneiderman RCT (2003) - PMID: 12966123

Landmark Trial: Only randomized controlled trial of ethics consultation in ICU.[10]

Design:

• Multicenter RCT in 7 hospitals
• Patients with value-laden treatment conflicts
• Randomized to ethics consultation vs usual care

Results:

• Ethics consultation reduced hospital days (8.7 vs 11.3 days, p=0.01)
• Reduced ICU days (4.2 vs 6.1 days, p=0.03)
• Reduced life-sustaining treatments in patients who died (0.51 vs 0.68 treatments/patient, p=0.03)
• No difference in mortality (intervention 30% vs control 25%, p=0.33)
• No difference in patient/family satisfaction

Interpretation:

• Ethics consultation reduced non-beneficial treatment without hastening death
• Facilitated earlier transition to comfort-focused care when appropriate
• Challenges concern that ethics consultation promotes treatment withdrawal

Other Studies

Orr et al. (2010) - PMID: 20185466:

• Prospective multicenter study of ethics consultation
• Improved family satisfaction with decision-making
• Reduced clinician moral distress

Dowdy et al. (1998) - PMID: 9620916:

• Retrospective study of ethics consultation
• Associated with shorter ICU length of stay
• No impact on mortality

Tapper et al. (2010) - PMID: 20643825:

• Systematic review of ethics consultation
• Found limited but generally positive evidence
• Called for more rigorous studies

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Ethics Consultation Models

Individual Consultant Model

Description: Single ethics consultant (usually physician, nurse, or bioethicist) provides consultation.

Advantages:

• Rapid response to urgent situations
• Personal relationship with clinical team
• Efficient for straightforward cases
• Available 24/7 in some institutions

Disadvantages:

• Limited perspective (single individual)
• Quality depends on consultant expertise
• Risk of burnout
• May lack authority for complex cases

Ethics Committee Model

Description: Standing committee meets to discuss cases (may be scheduled or urgent).

Composition (typical):

• Physicians (including intensivist)
• Nurses
• Social workers
• Chaplain/spiritual care
• Bioethicist
• Community representative
• Legal/risk management

Advantages:

• Multiple perspectives and expertise
• Deliberative process
• Perceived legitimacy
• Educational opportunity for members

Disadvantages:

• Slower response time
• Scheduling challenges
• May be cumbersome for urgent cases
• Committee dynamics may impede consensus

Hybrid Model

Description: Individual consultant for initial assessment and urgent cases; committee convened for complex or disputed cases.

Most Common Approach:

• Consultant provides immediate support and assessment
• Committee convened when:
  • Case involves fundamental disagreements
  • Consultant recommends committee review
  • Case raises policy-level questions
  • Potential for unilateral decision

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Ethics Consultation Process

Step 1: Referral and Information Gathering

Who Can Request:

• Any member of healthcare team
• Patient or family (some institutions)
• Hospital administration

Initial Assessment:

• Review medical records and clinical status
• Identify the ethical question(s)
• Determine urgency
• Identify stakeholders

Information Needed:

• Medical facts and prognosis
• Patient's decision-making capacity
• Known patient preferences (advance directive, prior statements)
• Family understanding and concerns
• Team perspectives and moral distress
• Institutional policies

Step 2: Consultation Meeting

Participants:

• Ethics consultant/committee
• Attending intensivist
• Bedside nurse
• Social worker
• Family (in some models)
• Others as relevant (chaplain, specialists)

Discussion Format:

• Present clinical case and ethical question
• Explore relevant facts and values
• Apply ethical frameworks
• Consider legal requirements
• Discuss options and implications
• Seek consensus on recommendations

Step 3: Recommendations

Nature of Recommendations:

• Advisory, not binding (in most models)
• Should be clear and actionable
• Based on ethical analysis, not personal opinion
• Document reasoning

Types of Recommendations:

• Specific treatment recommendations (withhold/withdraw)
• Communication strategies
• Family meeting facilitation
• Time-limited trials
• Second opinion
• Transfer to willing provider
• Referral to guardianship tribunal

Step 4: Follow-Up and Documentation

Documentation:

• Consultation request and reason
• Information reviewed
• Ethical analysis
• Recommendations
• Family and team responses

Follow-Up:

• Ensure recommendations are communicated
• Monitor implementation
• Provide ongoing support if needed
• Quality improvement review

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Conflict Resolution Strategies

Stepwise Approach to Conflict Resolution

When disagreements arise between clinical teams and families regarding treatment appropriateness, a graduated approach is recommended.[5,11]

Level 1: Enhanced Communication

Goal: Ensure family understands medical situation and prognosis; ensure team understands family perspective.

Strategies:

• Multiple family meetings (not just one)
• Different communication styles (e.g., different team member leads)
• Written information (prognostic data, disease information)
• Allow adequate time for processing
• Involve patient's own physician if transferred from elsewhere
• Clarify misunderstandings about prognosis or treatment effects

Specific Techniques:

• VALUE mnemonic (Curtis et al.):[12]

  • Value family statements
  • Acknowledge emotions
  • Listen actively
  • Understand patient as a person
  • Elicit questions

• Ask-Tell-Ask: Ask what family understands, tell information, ask what they understood

Documentation:

• Date, time, location, participants
• Information provided
• Family responses and concerns
• Questions asked and answered
• Plan agreed or points of disagreement

Level 2: Ethics Consultation

When to Escalate:

• Persistent disagreement after enhanced communication
• Family requests treatment team considers inappropriate
• Clinician moral distress
• Conflicting opinions among family members
• Uncertainty about appropriate course

Ethics Consultation Role:

• Neutral third party
• Facilitate communication
• Provide ethical analysis
• Help identify acceptable middle ground
• Make recommendations

Process:

• Formal request for consultation
• Information gathering by consultant
• Meeting with clinical team
• Meeting with family (separately or together)
• Deliberation and recommendations
• Documentation

Level 3: Second Medical Opinion

Purpose:

• Provides independent assessment of prognosis
• May reassure family that medical team's views are reasonable
• May identify alternative treatment options
• Satisfies family desire for "another opinion"

Process:

• Identify appropriate specialist (same specialty, ideally from different institution)
• Provide complete medical information
• Second opinion physician examines patient and reviews data
• Provides independent written opinion
• Share opinion with family

Considerations:

• Should not be seen as undermining primary team
• Second opinion may agree or disagree with primary team
• If second opinion differs significantly, requires reconciliation

Level 4: Time-Limited Trial

Definition: Agreement to continue treatment for a defined period with predetermined reassessment criteria.[13]

Purpose:

• Provides time to observe treatment response
• Gives family time to adjust to situation
• Avoids abrupt decisions
• Creates framework for reassessment

Elements:

• Specific time period (e.g., 5-7 days)
• Clear goals and milestones
• Criteria for "success" and "failure"
• Agreement on plan if trial fails
• Documentation of agreement

Example: "We will continue current treatment for 5 days. If vasopressor requirements have decreased and there are signs of improvement, we will continue. If requirements have increased and multi-organ failure has progressed, we will meet again to discuss transitioning to comfort-focused care."

Advantages:

• Allows family hope while creating structure
• Avoids permanent decisions based on uncertain prognosis
• Clinically appropriate when response to treatment uncertain

Limitations:

• May merely delay difficult decisions
• Repeated trials can prolong suffering
• Requires clear criteria to be effective

Level 5: Institutional Review

When Required:

• Ethics consultation has not resolved conflict
• Team is considering unilateral decision
• Case raises institutional policy questions

Process:

• Formal review by hospital administration or policy committee
• May involve legal counsel
• Ensures institutional support for team's position
• Documents due process

Functions:

• Confirm that appropriate process has been followed
• Review legal requirements
• Consider transfer options
• Authorize final team position

Level 6: External Review

Options:

• Guardianship Tribunal: State body with legal authority to authorize treatment decisions
• Court order: In rare cases requiring judicial determination
• Coroner's office: Consultation if anticipated withdrawal will lead to coronial case

Guardianship Tribunal Process:

1. Application by hospital (or family)
2. Appointment of hearing date (may be urgent)
3. Submission of medical evidence
4. Hearing with opportunity for all parties to be heard
5. Written decision
6. Right of appeal

When to Consider Court Order:

• Novel legal questions
• High-profile cases
• Risk of significant litigation
• Guardianship tribunal unavailable or inappropriate

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Mediation Techniques

Mediation Principles:

• Neutral third party facilitates discussion
• Goal is mutual understanding and agreement
• Focus on interests rather than positions
• Creative problem-solving to find acceptable solutions

Techniques for ICU Conflicts:

1. Separate meetings first: Meet family and team separately to understand each perspective
2. Reframe positions as interests: "We want everything done" → "We want to be sure he has every chance"
3. Find common ground: Both family and team want patient not to suffer
4. Acknowledge emotions: Grief, fear, guilt, distrust
5. Explore values: What would patient want? What does quality of life mean?
6. Generate options: Time-limited trial, second opinion, transfer
7. Focus on patient: Shift from "what family wants" vs "what team wants" to "what's best for patient"

Barriers to Resolution:

• Distrust of medical system (particularly relevant for Indigenous families, previous negative experiences)
• Guilt ("If we agree to stop, we're killing him")
• Family conflict (disagreement among family members)
• Religious beliefs (sanctity of life, miracles)
• Cultural factors (decision-making norms differ from Western model)
• Poor communication (medical jargon, rushed meetings)
• Prognostic uncertainty (family clings to uncertainty as hope)

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ANZICS-CORE Statement

Statement on Care and Decision-Making at the End of Life

The Australian and New Zealand Intensive Care Society (ANZICS) provides authoritative guidance for end-of-life care in ICU.[14]

Key Principles

1. Patient-centered care: Decisions should reflect patient's values, preferences, and goals
2. Shared decision-making: Partnership between clinicians, patients, and families
3. Quality of life: Consider functional outcomes, not just survival
4. Cultural safety: Respect for diverse cultural, religious, and spiritual beliefs
5. Communication: Clear, honest, compassionate communication
6. Palliative care: Early integration of palliative care principles
7. Support for staff: Recognition of moral distress and provision of support

Recommendations

Decision-Making Process:

• Early and repeated goals-of-care discussions
• Multidisciplinary team involvement
• Family meetings with adequate time and follow-up
• Documentation of discussions and decisions
• Ethics consultation when conflict arises

Withdrawal of Life-Sustaining Treatment:

• Based on patient's wishes (if known) or best interests
• Consensus between team and family preferred
• Clear documentation of decision-making process
• Symptom management as priority during withdrawal
• Family presence encouraged

Conflict Resolution:

• Graduated approach (enhanced communication → ethics consultation → second opinion → tribunal)
• Institutional policies should guide practice
• Unilateral decisions only as last resort with appropriate process

Cultural Considerations:

• Aboriginal and Torres Strait Islander peoples: community-based decision-making, cultural protocols
• Māori: whānau-centered approach, tikanga observance
• CALD populations: interpreter services, cultural liaison

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ANZICS-CORE Quality Indicators

Key Metrics:

• Proportion of ICU deaths following goals-of-care discussions
• Time from admission to goals-of-care discussion
• Documentation of advance care planning
• Family satisfaction with end-of-life care
• Staff wellbeing and moral distress measures

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Peoples

Cultural Context

Community-Based Decision-Making:

• Decisions are not solely individual; family and community have roles
• Elders may hold decision-making authority
• Extended family ("mob") involvement expected
• Consensus among relevant family members sought

Spiritual and Cultural Beliefs:

• Concept of "sorry business" surrounding death
• Desire to die "on country" (traditional lands)
• Spiritual connection to land and ancestors
• Traditional healing practices may be important

Historical Context:

• Legacy of colonization, stolen generations, institutional discrimination
• Distrust of health system due to past experiences
• Higher rates of chronic disease, lower life expectancy
• Barriers to accessing healthcare, particularly in remote areas

Communication Considerations

Aboriginal Health Workers and Liaison Officers:

• Essential for culturally appropriate communication
• Help navigate cultural protocols
• Bridge between Western medicine and traditional approaches
• Should be involved in family meetings

Communication Style:

• "Yarning" approach: storytelling, indirect communication
• Avoid direct questions about death initially
• Use terms like "very sick," "might not get better" before "dying"
• Allow time for family discussion and consensus
• Avoid eye contact (can be seen as disrespectful)
• Speak to appropriate family member (may not be next of kin in Western sense)

Language Considerations:

• English may be second, third, or fourth language
• Use interpreters when needed (many Indigenous languages)
• Simple language, avoid medical jargon
• Check understanding frequently

End-of-Life Practices

Cultural Protocols:

• Family presence at bedside (often many people)
• Smoking ceremonies and traditional rituals
• Traditional items may be placed with patient
• Specific cultural restrictions (who can see body, touching head is sacred)
• Need for body to be returned to country for burial

Decision-Making:

• Consensus among Elders and family preferred
• May resist withdrawal decisions due to distrust of healthcare system
• May need time to bring family members from remote areas
• Community input may be sought

Practical Considerations:

• Allow flexibility in visiting hours
• Accommodate larger numbers of family members
• Provide space for cultural practices
• Coordinate with community for funeral arrangements
• RFDS for transport of body to remote communities

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Māori (New Zealand)

Tikanga (Cultural Practices)

Whānau (Family):

• Extended family is fundamental unit for decision-making
• Individual decisions seen in context of family relationships
• Whānau involvement in all significant decisions

Kaumātua (Elders):

• Hold wisdom and authority
• May speak on behalf of family
• Should be consulted for major decisions

Core Values:

• Manaakitanga: Hospitality, care, respect
• Whakapapa: Genealogy, connection to ancestors
• Tapu: Sacred, restrictions around body and death
• Noa: Return to ordinary state after tapu restrictions
• Wairua: Spiritual dimension

Communication

Whakawhanaungatanga:

• Building relationships before addressing difficult topics
• Establishing connections (shared history, common ground)
• Takes time but essential for trust

Māori Health Workers:

• Essential for culturally safe communication
• Navigate tikanga requirements
• Facilitate communication with whānau

Language:

• Te reo Māori may be preferred for some discussions
• Culturally appropriate terminology
• Avoid direct discussion of death initially

End-of-Life Practices

Tangihanga (Funeral):

• Extended mourning period (2-3 days)
• Body lies in state on marae
• Important for whānau to be together

Return to Marae:

• Strong preference for dying to occur near whānau
• Body returned to marae for tangihanga
• Hospital death may require modification of tikanga

Body Care:

• Tapu (sacred) considerations around body after death
• Specific protocols for washing and preparing body
• Karakia (prayers) and waiata (songs)

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Culturally and Linguistically Diverse (CALD) Populations

Language Considerations

Professional Interpreters:

• Essential for complex medical discussions
• Never use family members for interpreting (may filter information, conflict of interest)
• Phone interpreters available 24/7 (Translating and Interpreting Service: 131 450)
• In-person interpreters preferred for sensitive discussions

Communication Techniques:

• Allow extra time for translation
• Verify understanding through back-translation
• Written information in appropriate language
• Visual aids and diagrams

Cultural Differences

Disclosure Preferences:

• Some cultures practice "protective nondisclosure" (not telling patient bad news)
• Family may request information be withheld from patient
• Requires careful navigation; patient autonomy must be respected
• Ask patient (through interpreter) who they want information shared with

Decision-Making Structures:

• Family-based decision-making in many cultures
• Eldest son/male authority in some cultures
• Women may be excluded from discussions in some cultures
• Respect cultural norms while ensuring patient interests protected

Religious Considerations

Chaplaincy Services:

• Hospital chaplains can provide support and guidance
• Can contact religious leaders from patient's community
• Facilitate religious practices within hospital constraints

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Specific Scenarios

Family Demands "Everything Be Done"

Common Scenario: Family insists on continued aggressive care when clinical team believes treatment is futile.

Approach:

1. Explore what "everything" means:

   • "Can you help me understand what you mean by 'everything'?"
   • Often reflects fear of abandonment, not specific treatments

2. Understand underlying concerns:

   • Fear of "giving up"
   • Guilt about past relationship issues
   • Religious beliefs about miracles
   • Distrust of medical system
   • Denial/difficulty accepting prognosis

3. Reframe goals:

   • "We will always do everything to keep your father comfortable"
   • "We will never abandon him"
   • "The question is what 'best care' looks like now"

4. Provide prognostic information clearly:

   • Use numeric estimates where possible
   • "Less than 1 in 100 patients with this condition survive"
   • Avoid false hope but acknowledge uncertainty

5. Time-limited trial (if appropriate):

   • "Let's give treatment X days and reassess"
   • Clear criteria for success/failure
   • Agreed plan if trial fails

6. Ethics consultation if disagreement persists

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Clinician Moral Distress

Definition: Psychological distress when clinicians know the right action but are constrained from taking it.[15]

Common Causes in ICU:

• Providing treatment clinician considers futile
• Witnessing patient suffering without benefit
• Family demands for inappropriate treatment
• Resource constraints preventing optimal care
• Inadequate time for family communication

Manifestations:

• Emotional exhaustion, burnout
• Anger, frustration
• Withdrawal, cynicism
• Physical symptoms (sleep disturbance, fatigue)
• Intention to leave profession

Institutional Responses:

• Debriefing after difficult cases
• Ethics consultation to address underlying conflict
• Peer support programs
• Schwartz Center Rounds
• Employee assistance programs
• Recognition of moral distress as occupational hazard

CICM/ANZICS Guidance:

• Staff wellbeing is institutional responsibility
• Leaders should create culture where moral distress can be expressed
• Ethics consultation should be accessible
• Time for reflection and debriefing

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Disagreement Among Family Members

Scenario: Adult children disagree about treatment for parent.

Approach:

1. Convene family meeting with all key members:

   • Ensure all voices heard
   • Understand each person's perspective

2. Refocus on patient's wishes:

   • "What would your mother have wanted?"
   • "Did she ever discuss her wishes about this kind of situation?"
   • Shift from "what I want for her" to "what she would want"

3. Identify substitute decision-maker:

   • Legal hierarchy (varies by jurisdiction)
   • May need to clarify authority

4. Facilitate family discussion:

   • Allow family time to talk among themselves
   • Offer separate meetings if family conflict is high

5. Mediation:

   • Ethics consultation can provide neutral facilitation
   • Social work involvement

6. Guardianship tribunal if unresolvable

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Religious Objection to Withdrawal

Scenario: Family refuses withdrawal based on religious beliefs (e.g., "waiting for a miracle").

Approach:

1. Acknowledge and respect beliefs:

   • "I understand your faith is very important to you"
   • "Many people find great comfort in their faith during difficult times"

2. Explore beliefs non-judgmentally:

   • "Can you tell me more about how your faith guides you in this decision?"
   • Understand specific beliefs (sanctity of life, hope for divine intervention)

3. Involve chaplain/religious leader:

   • Hospital chaplain can provide support
   • Patient's own religious leader may be helpful
   • Some religious leaders can help family understand withdrawal is acceptable in their tradition

4. Find common ground:

   • Most religions accept withholding futile treatment
   • Focus on patient comfort and dignity
   • "We can pray for a miracle while also ensuring he is not suffering"

5. Time-limited trial:

   • May be acceptable compromise
   • "Let's give God 5 more days to work, and then reassess"

6. Respect genuine beliefs while not abandoning professional judgment

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SAQ Practice Questions

SAQ 1

Question:

A 72-year-old male with metastatic pancreatic cancer was admitted to ICU 10 days ago with septic shock secondary to cholangitis. Despite source control and appropriate antibiotics, he remains on high-dose norepinephrine (0.5 mcg/kg/min), has developed ARDS requiring PEEP 14 cmH2O and FiO2 0.8, and has acute kidney injury requiring CRRT. His SOFA score is 18 and lactate remains 6 mmol/L. His oncologist informs you that his cancer has progressed on second-line chemotherapy and he has a life expectancy of weeks without ICU intervention. He has no advance care directive. His wife and three adult children are at the bedside. The nursing staff have expressed significant moral distress about continuing aggressive care.

(a) Define the different types of medical futility and discuss how they apply to this case. (6 marks)

(b) Outline the role and process of ethics consultation in this scenario. (5 marks)

(c) The family is adamant that "he is a fighter and would want everything done." Describe your approach to conflict resolution. (6 marks)

(d) Discuss how you would address nursing staff moral distress. (3 marks)

Model Answer:

(a) Types of medical futility and application to case: (6 marks)

Quantitative futility (1.5 marks):

• Treatment has <1% probability of achieving intended goal
• Application: SOFA 18 with persistent lactate elevation predicts mortality >95%; survival with underlying advanced cancer extremely unlikely

Qualitative futility (1.5 marks):

• Treatment may sustain life but with quality patient would find unacceptable
• Application: Even if survival possible, functional outcome after prolonged ICU stay with metastatic cancer likely very poor; need to explore patient's prior expressed values

Physiological futility (1.5 marks):

• Treatment cannot achieve physiological goal
• Application: Not clearly applicable here; organs are responding to support, but underlying disease (cancer) is progressing despite treatment

Normative futility/Potentially Inappropriate Treatment (1.5 marks):

• Treatment conflicts with professional norms; current preferred terminology is "potentially inappropriate treatment"
• Application: Continued aggressive ICU care for patient with progressive metastatic cancer and multi-organ failure likely meets PIT criteria; treatment may prolong dying without benefiting patient

(b) Role and process of ethics consultation: (5 marks)

Role (2 marks):

• Facilitate communication between team and family
• Provide ethical analysis of situation
• Mediate conflict and identify potential middle ground
• Make advisory recommendations (not binding decisions)
• Support clinicians experiencing moral distress

Process (3 marks):

• Formal request for ethics consultation from clinical team
• Information gathering: medical facts, prognosis, family dynamics, patient's known values
• Meeting with clinical team to understand concerns
• Meeting with family to understand perspective and explore patient's values
• Deliberation applying ethical frameworks (principlism, considering autonomy, beneficence, non-maleficence)
• Recommendations: options may include time-limited trial, transition to comfort care, continued aggressive care with reassessment
• Documentation of consultation and recommendations
• Follow-up to ensure recommendations are communicated and implemented

(c) Conflict resolution approach: (6 marks)

Enhanced communication (2 marks):

• Arrange formal family meeting in quiet, private environment
• Use VALUE mnemonic: value family statements, acknowledge emotions, listen actively
• Explore what "everything done" means to family; understand underlying concerns (fear of abandonment, guilt, hope)
• Provide clear prognostic information: explain SOFA score, lactate, cancer prognosis
• Explore patient's values: "Did he ever discuss what he would want in this situation?"

Reframe discussion (1.5 marks):

• Shift from "what we want" vs "what you want" to "what would he want"
• "We will never abandon him; we will always provide excellent care"
• Distinguish between prolonging life and prolonging dying

Time-limited trial (1.5 marks):

• May offer structured trial: "Let's give it 5 more days with specific goals"
• Clear criteria for success (reducing vasopressor requirements, improving lactate) and failure
• Agreed plan if trial fails (transition to comfort-focused care)

Escalation if needed (1 mark):

• Ethics consultation if conflict persists
• Second medical opinion from another intensivist or palliative care specialist
• Document all discussions; guardianship tribunal as last resort

(d) Addressing nursing moral distress: (3 marks)

• Acknowledge distress (1 mark): Validate that moral distress is normal response; nurses' concerns are legitimate
• Team debriefing (1 mark): Arrange formal debriefing session; allow staff to express concerns; involve social work/chaplain
• Action (1 mark): Escalate to ethics consultation; communicate team's plan to address situation; provide updates to nursing staff; ensure nursing voice is heard in family meetings; provide access to employee assistance program if needed

Total: 20 marks

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SAQ 2

Question:

A 55-year-old Aboriginal woman from a remote community in the Northern Territory was transferred to your tertiary ICU 8 days ago with severe community-acquired pneumonia, septic shock, and ARDS. She has multiple comorbidities including end-stage renal failure on dialysis, type 2 diabetes with complications, and ischemic heart disease. Despite maximal therapy, she has developed refractory hypotension and worsening multi-organ failure. The ICU team believes that continued aggressive care is futile. Her husband is at the bedside, and extended family including a community Elder have arrived from the remote community. The family has expressed distrust of the hospital and stated they want her to "go back to country."

(a) Describe the ethical frameworks that should guide decision-making in this case, with particular reference to cultural considerations. (5 marks)

(b) Outline your approach to goals-of-care discussion with this family, incorporating culturally appropriate communication strategies. (6 marks)

(c) The family requests transfer back to the remote community for her to "die on country." Discuss the clinical, ethical, and practical considerations in responding to this request. (5 marks)

(d) Explain the role of the ANZICS-CORE Statement on Care and Decision-Making at the End of Life in guiding practice in this case. (4 marks)

Model Answer:

(a) Ethical frameworks with cultural considerations: (5 marks)

Principlism (2 marks):

• Autonomy: In Aboriginal culture, decision-making is often community-based rather than individual; family and Elders may have decision-making authority; autonomy expressed through community consensus rather than individual directive
• Beneficence/Non-maleficence: Best interests include cultural and spiritual dimensions; dying "on country" may be in patient's cultural best interests; avoiding prolonged dying in hospital may reduce harm
• Justice: Historical disadvantage and healthcare access barriers for Aboriginal peoples; equitable access to culturally safe care

Care ethics (1.5 marks):

• Emphasizes relational and contextual aspects of decision-making
• Attentiveness to family's distrust of healthcare system (historical context of colonization, stolen generations)
• Responsiveness to cultural needs and preferences
• Focus on caring relationship with family, not just patient

Cultural considerations (1.5 marks):

• Understand that Aboriginal decision-making involves community, not just individual
• Elder may hold authority in family discussions
• Spiritual connection to land ("on country") is fundamental
• Historical trauma affects trust in healthcare institutions
• Western concepts of advance directives may not align with cultural practices

(b) Approach to goals-of-care discussion: (6 marks)

Preparation (1.5 marks):

• Involve Aboriginal Health Worker (AHW) or Aboriginal Liaison Officer (ALO) in all discussions
• Ensure adequate time; Aboriginal families may need longer to reach consensus
• Allow extended family and Elder to be present
• Choose quiet, private environment; accommodate larger group

Communication strategies (2.5 marks):

• Use "yarning" approach: indirect storytelling rather than direct questions
• Ask AHW to help initiate conversation appropriately
• Avoid direct discussion of "death" initially; use terms like "very sick," "might not get better"
• Acknowledge Elder's role; direct key information through appropriate family structure
• Allow silences; don't rush the conversation
• Use simple language; avoid medical jargon; check understanding

Content of discussion (2 marks):

• Explain current medical situation honestly but sensitively
• Explore patient's values as understood by family
• Ask about cultural and spiritual needs
• Discuss what "good care" looks like for this patient
• Explain options: continued aggressive care, transition to comfort care, transfer back to community if feasible
• Respect family's need to discuss among themselves; offer to reconvene after family consultation

(c) Request for transfer back to country: (5 marks)

Clinical considerations (1.5 marks):

• Patient is on high-dose vasopressors, CRRT, mechanical ventilation
• Transfer to remote community likely not medically feasible; risk of death during transport
• Limited medical facilities in remote community
• Aeromedical retrieval (RFDS) would be required

Ethical considerations (2 marks):

• Dying "on country" is culturally very significant; strong ethical argument to support if feasible
• Must balance cultural wishes against patient safety and dignity during transport
• If transfer truly not possible, must acknowledge this with sensitivity
• Explore alternatives: bring elements of country to patient (traditional items, family, cultural practices in hospital); transfer to regional hospital closer to community if patient becomes stable enough

Practical considerations (1.5 marks):

• Discuss with RFDS regarding feasibility of transfer for palliative purpose
• If transfer not possible: facilitate cultural practices in hospital (smoking ceremony, family presence, traditional items)
• Ensure body can be transported back to community after death
• Coordinate with community clinic and family regarding arrangements
• Document family wishes and discussions

(d) ANZICS-CORE Statement guidance: (4 marks)

Key principles (2 marks):

• Patient-centered care: decisions should reflect patient's values, which include cultural and spiritual dimensions
• Shared decision-making: partnership with family, recognizing Aboriginal community-based decision structures
• Cultural safety: respect for diverse cultural, religious, and spiritual beliefs is explicitly emphasized
• Quality of care: includes cultural appropriateness, not just clinical outcomes

Application to case (2 marks):

• Statement supports graduated conflict resolution if disagreement arises
• Emphasizes early and repeated goals-of-care discussions
• Supports involvement of cultural liaison (AHW/ALO)
• Recommends ethics consultation if conflict persists
• Acknowledges importance of Aboriginal and Torres Strait Islander cultural considerations specifically
• Supports palliative approach when aggressive treatment not benefiting patient

Total: 20 marks

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Viva Voce Scenarios

Viva 1: Managing Family Demand for Futile Treatment

Candidate Prompt:

"A 68-year-old male with advanced COPD (FEV1 0.6L, on long-term oxygen therapy) and metastatic lung cancer was admitted to ICU 7 days ago with respiratory failure secondary to pneumonia. Despite maximum ventilatory support (FiO2 1.0, PEEP 18), his oxygenation remains poor (PaO2 55 mmHg). He has developed septic shock requiring vasopressors and acute kidney injury. His oncologist confirms that his cancer has progressed on treatment and there are no further oncological options. He has no advance care directive. His daughter, who is his next of kin and substitute decision-maker, is demanding CPR and continued aggressive resuscitation 'no matter what.' The nursing staff are extremely distressed about continuing care."

Examiner Questions and Model Answers:

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Q1: How would you define medical futility, and does it apply to this case?

Model Answer:

Medical futility has several dimensions:

Quantitative futility: Treatment has less than 1% probability of achieving its intended goal. This patient has end-stage COPD, metastatic cancer, and multi-organ failure despite maximal treatment - survival probability is extremely low, likely approaching quantitative futility.

Qualitative futility: Even if treatment prolongs life, the quality of life would be one the patient would consider unacceptable. Without knowing patient's values, this is harder to determine, but survival with severe disability from prolonged ICU stay in someone with end-stage underlying diseases would be relevant.

Physiological futility: Treatment cannot achieve its physiological aim. In this case, oxygenation is failing despite maximal support - this approaches physiological futility for respiratory support.

Normative/Potentially inappropriate treatment: This is the current preferred terminology. Continued aggressive ICU care for patient with end-stage COPD and metastatic cancer with multi-organ failure likely constitutes potentially inappropriate treatment - treatment that has minimal probability of benefit and may cause harm through prolonged dying.

In summary, multiple futility concepts apply; this case likely meets criteria for potentially inappropriate treatment.

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Q2: The daughter insists "he is a fighter and would want everything done." How would you respond?

Model Answer:

I would use a stepwise approach:

First, explore what this means to her:

• "Can you help me understand what you mean by 'everything'?"
• Often families fear abandonment rather than wanting specific interventions
• "Tell me more about your father - what kind of person is he?"

Understand underlying concerns:

• Fear of "giving up" on him
• Guilt about past relationship
• Difficulty accepting prognosis
• May not understand that "everything" includes causing suffering

Acknowledge and validate:

• "I can see how much you love your father"
• "It's clear you want the best for him"
• VALUE mnemonic - value her statements, acknowledge emotions, listen

Reframe the discussion:

• "We will never abandon him; we will always provide excellent care"
• "The question is what excellent care looks like now"
• "What do you think your father would want if he could see himself like this?"

Provide clear prognostic information:

• "I need to be honest with you about what we're seeing"
• Explain specific medical situation in plain language
• "Even with CPR, in someone with his condition, survival is extremely unlikely"

Explore patient's values:

• "Did he ever discuss with you what he would want in a situation like this?"
• "What was most important to him in life?"

If these approaches don't achieve progress, I would move to ethics consultation.

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Q3: What is the role of ethics consultation in this case, and how would you initiate it?

Model Answer:

Indications for ethics consultation in this case:

• Persistent disagreement between clinical team and family
• Family requesting treatment team considers inappropriate
• Significant nursing moral distress
• Complex ethical issues requiring structured analysis

Role of ethics consultation:

• Provide neutral third-party perspective
• Facilitate communication between team and family
• Apply ethical frameworks systematically
• Identify potential middle ground
• Make advisory recommendations
• Document process for legal protection

How to initiate:

• Formal consultation request through hospital system
• Explain to family: "I'd like to involve our ethics consultant to help us work through this together"
• Frame positively: not "calling in reinforcements" but "getting additional support for this difficult situation"

Ethics consultation process:

• Consultant gathers information (medical facts, family dynamics, patient's known values)
• Meets with clinical team
• Meets with family (may be separate or combined meeting)
• Deliberates applying ethical frameworks
• Makes recommendations
• Documents consultation

Expected outcomes:

• Schneiderman study showed ethics consultation reduces ICU LOS without increasing mortality
• May help family understand situation better
• May identify time-limited trial as compromise
• Provides documentation of due process if conflict continues

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Q4: If the daughter continues to insist on CPR despite ethics consultation, what are your options?

Model Answer:

Continued conflict resolution:

• Second medical opinion from another intensivist or palliative care physician
• Time-limited trial with specific goals and timeline
• Offer to allow family to arrange transfer to another willing provider
• Pastoral care or chaplain involvement if religious concerns

Consider DNACPR as medical decision:

• CPR in this patient likely constitutes physiologically futile treatment
• Patient has no reasonable chance of surviving CPR with meaningful outcome
• ATS/AACN/ACCP/ESICM/SCCM policy statement supports that clinicians should not be required to provide CPR that cannot benefit patient
• However, process must be followed

If considering unilateral DNACPR:

• Ensure ethics consultation has occurred
• Institutional review and support
• Senior medical leadership agreement
• Legal review
• Offer transfer opportunity to family
• Documentation must be meticulous
• Guardianship tribunal if family challenges decision

Communication with family:

• Explain that CPR cannot be expected to work and would cause suffering without benefit
• Emphasize that we will provide excellent comfort care
• "We will be with him, keeping him comfortable, and you can be at his bedside"
• This is not abandonment

Important caveat:

• Unilateral decisions are legally and ethically fraught
• Preferred approach is always to achieve consensus
• In Australia, taking case to guardianship tribunal is safer than unilateral decision

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Q5: How would you address the nursing staff's moral distress?

Model Answer:

Immediate response:

• Acknowledge their distress: "I understand how difficult this is. Your concerns are valid."
• Explain plan: "This is what we're doing to address the situation" (ethics consultation, family meetings, etc.)
• Invite input: "What do you think would help?"

Debriefing:

• Arrange formal team debriefing session
• Include bedside nurses, senior nursing staff, social work, chaplain
• Allow expression of concerns and emotions
• Discuss ethical principles involved
• Explain process being followed

Ongoing support:

• Keep nursing staff informed about family discussions
• Include nursing representative in family meetings
• Acknowledge the burden of providing care they consider futile
• Consider rotating nursing assignments if distress severe
• Employee assistance program referral if needed

Systemic responses:

• Ethics consultation addresses underlying conflict
• Escalate to resolution rather than continuing indefinitely
• Institutional support for staff experiencing moral distress
• Schwartz Center Rounds or similar programs for reflective practice

Professional responsibility:

• As intensivist, I have responsibility for staff wellbeing
• Prolonged provision of inappropriate treatment harms staff as well as patient
• Must advocate for resolution

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Viva 2: Ethics Consultation Process and Conflict Resolution

Candidate Prompt:

"You are the intensive care consultant in a tertiary hospital. A 45-year-old woman with no significant past medical history suffered an out-of-hospital cardiac arrest 12 days ago. Despite therapeutic hypothermia and optimal neurocritical care, she remains comatose with absent brainstem reflexes except for weak pupillary responses. CT and MRI show severe diffuse hypoxic-ischemic injury. EEG shows burst suppression. The neurology team believes she has virtually no chance of meaningful neurological recovery and has recommended transition to comfort care. Her husband agrees with this assessment. However, her parents (who have flown in from overseas) are adamant that she should continue on full support, citing their religious beliefs and stating they are 'waiting for a miracle.' There is significant conflict between the husband and parents."

Examiner Questions and Model Answers:

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Q1: Describe the ethical principles relevant to this case and how they might conflict.

Model Answer:

Autonomy:

• Patient's own wishes unknown (no advance directive, no prior documented discussions)
• Substituted judgment should guide decision - what would she have wanted?
• Conflict: husband and parents disagree on what she would want
• Issue of who holds decision-making authority

Beneficence:

• Acting in patient's best interests
• If prognosis is truly hopeless, best interests may favor comfort care
• Parents may see continued life support as in her best interests (religious perspective)

Non-maleficence:

• Continued aggressive care causes harm: invasive procedures, prolonged dying, loss of dignity
• Balanced against harm of potentially premature withdrawal if any recovery possible

Justice:

• ICU resources are limited
• Patient occupying bed that could benefit another
• Though rarely invoked at bedside, relevant at system level

Principal conflicts:

• Autonomy vs beneficence: if patient's wishes unknown, who decides what's best?
• Husband vs parents: different interpretations of best interests/patient values
• Respect for religious beliefs vs medical judgment about prognosis

Religious dimension:

• Parents' belief in miracles is genuine religious conviction
• Must respect while not abandoning medical judgment
• Care ethics would emphasize maintaining relationship while working toward resolution

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Q2: Who is the legal substitute decision-maker in this case?

Model Answer:

Legal hierarchy (varies by jurisdiction):

• In most Australian states/territories, spouse has priority over parents for adult patient
• Husband is likely the legal substitute decision-maker
• Parents' authority is secondary

Specific jurisdiction considerations:

• Victoria (Medical Treatment Planning and Decisions Act 2016): Spouse/domestic partner takes priority over parents
• NSW (Guardianship Act 1987): "Person responsible" hierarchy places spouse above parents
• Queensland: Similar hierarchy

Practical application:

• Husband has legal authority to make treatment decisions
• However, should attempt to achieve consensus with parents
• If fundamental disagreement, husband's decision should prevail
• Parents can apply to guardianship tribunal if they believe husband is not acting in patient's interests

Important considerations:

• Legal authority doesn't mean ignoring parents
• Should still involve parents in discussions
• May need ethics consultation and mediation
• Documentation of SDM authority is important

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Q3: How would you conduct an ethics consultation in this case?

Model Answer:

Request consultation:

• Formal request documenting the ethical question
• "Conflict between family members regarding treatment decisions for patient with severe hypoxic brain injury"

Information gathering:

• Review medical records and prognosis
• Speak with neurology team about prognostic certainty
• Identify patient's known values/preferences (from husband, parents, friends)
• Understand each party's perspective and concerns

Meeting with clinical team:

• Confirm prognosis and team consensus
• Explore any uncertainty
• Understand team's moral position
• Address nursing/staff concerns

Meeting with husband:

• Understand his perspective on patient's values
• Explore any prior discussions with patient about these situations
• Assess his understanding of prognosis
• Provide support for his role as SDM

Meeting with parents:

• Understand their perspective and concerns
• Explore their knowledge of daughter's values
• Understand religious beliefs and how they apply
• Acknowledge their distress; validate their role as parents

Joint family meeting (if appropriate):

• Facilitate communication between husband and parents
• Focus on patient: "What would she want?"
• Seek common ground
• May need to clarify SDM authority if impasse

Recommendations:

• Advisory recommendations based on ethical analysis
• May include time-limited trial, additional prognostic testing, second opinion
• May affirm husband's authority if consensus impossible
• Document recommendations and reasoning

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Q4: The parents state that withdrawing treatment is "murder" and threaten legal action. How do you respond?

Model Answer:

Immediate response:

• Remain calm and empathetic: "I understand this is extremely distressing"
• Don't become defensive or adversarial
• Acknowledge their love for their daughter

Address the "murder" concern:

• Explain distinction between killing and allowing to die
• "We are not causing her death; we are allowing her underlying brain injury to take its natural course"
• "Withdrawal of life support when treatment cannot benefit patient is not illegal or unethical"
• "We are not ending life; we are removing treatments that are only prolonging dying"

Legal considerations:

• Withdrawal of futile treatment is legally permissible in Australia
• Case law supports medical teams in these situations (Northridge, Messiha)
• Document everything meticulously
• Involve hospital legal/risk management

Continued engagement:

• Offer second medical opinion
• Suggest chaplain involvement if religious concerns
• Ethics consultation if not already involved
• Time-limited trial may be acceptable compromise

If legal action threatened:

• Inform hospital legal counsel
• May need to maintain status quo pending legal review
• Can apply to guardianship tribunal for authoritative decision
• Tribunal can authorize or decline withdrawal based on patient's best interests

Important:

• Do not let threat of legal action prevent appropriate care
• Proper process and documentation is best protection
• Most threatened litigation does not proceed if process was followed

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Q5: After ethics consultation and multiple family meetings, husband agrees to withdrawal but parents remain opposed. How do you proceed?

Model Answer:

Confirm legal authority:

• Husband is substitute decision-maker
• His consent is legally sufficient to proceed
• Document this explicitly

Final family meeting:

• Attempt one final meeting with all parties
• Explain that husband has legal authority
• Emphasize that decision has been made carefully with his knowledge of patient's values
• Ask parents if they want to be present during withdrawal
• Offer pastoral care and support

Proceed with withdrawal:

• Plan withdrawal process with husband's consent
• Offer parents opportunity to be present or have time with daughter beforehand
• Provide excellent symptom management
• Family presence encouraged if they wish

Support for parents:

• Acknowledge this is extremely difficult for them
• They may feel powerless and excluded
• Offer chaplain, social work support
• They remain her parents; their grief is real
• Document that they were informed and offered opportunity to be present

Documentation:

• Record entire decision-making process
• Document ethics consultation and recommendations
• Record husband's consent as SDM
• Record that parents were informed and their objection
• Record that proper process was followed

Post-death:

• Offer bereavement follow-up to all family
• May need to facilitate discussion between husband and parents
• Support available regardless of conflict during decision