College Answer

This is a common scenario in the care of the critically ill.  The usual ethical principles need to be considered:

•    Autonomy (patient’s right to choose or refuse therapies),

•    Beneficence (obligation to further the patient’s interests),

•    Nonmaleficence (not inflict evil or harm, including refraining from interventions which are more likely to be of harm than benefit), and

•    Justice (social justice, including fair allocation of societal resources).

The key premise is one of full disclosure regarding medical condition, understanding of patient’s  wishes  (direct  or  via  appropriate  surrogate),  and  a  collaborative  plan  of management which clearly outlines priorities (eg. relief of pain and suffering versus prolongation  of  life  at  all  costs)  and  plans  regarding  interventions  (eg.  analgesic medications, removal of ETT, not for futile procedures or therapies [eg. CPR]).

One proposed tool is the PEACE tool, which considers:

•    Physical symptoms (including pain, nausea, other side effects)

•    Emotive and cognitive symptoms (including anxiety)

•    Autonomy (sense of control and participation in decision making)

•    Closure of life affairs (spend time with family, others to visit etc.)

•    Economic  (assistance,  arrangements,  insurance  etc)  and  existential  issues  (eg. religious and spiritual)

Conflict resolution is essential, and is usually prevented by adequate communication with patient and families involving complete and open discussion, but on occasions may require external input (eg. external specialist, courts etc)