Question 13

College answer

Not available.

Discussion

It is correct to state that "the ANZICS statement on care and decision making at the end of life for the critically ill outlines the process for shared decision making about treatment options",  but it is not clear how this part of the stem influences the expected answer.  Does this mean that the answer to the question about the ICU physician's responsibilities should be based on the ANZICS document? Reading between the lines, that is what is implied here, but it would be nice to have things spelled out more clearly, eg. "outline the ICU physician’s responsibilities in the care and decision making at the end of life for the critically ill, as described in the relevant ANZICS statement" would have been an entirely unambiguous test of the trainee's familiarity with that document. 

The responsibilities of the intensivist in the process of shared decision making at the end of life for the critically ill:

• Governance
  • The intensivist should take a leadership position in end-of-life discussions within the ICU
• Key skills and knowledge
  • Ability to assess a patients capacity
  • Skills for communicating effectively with dying patients, their families, and other health professionals
  • Familiarity with the relevant local laws and guidelines
  • Expertise in effective symptom control in the dying ICU patient
• Determining treatment goals
  • Seek, identify and comply with the patients' expressed preferences
  • Discuss the reasons for withholding or withdrawing therapy with the patient or surrogate in specific patient-focused language and in an atmosphere of mutual respect
  • Involve cultural advisers and translators where the cultural or language differences might impede communication and understanding.
  • Seek to prevent and resolve conflict
• Documentation
  • Assist patients and substitute decision-makers to document the decision
  • Formally and clearly document any discussions
  • Audit compliance with documentation
• Management
  • Individually tailor an end-of-life plan for each patient
  • Coordinate pharmacological treatments for symptom control with the sole intention of relieving suffering
  • Recognise and present opportunities for organ and tissue donation
  • Arrange post-bereavement support for the family
  • Carry out follow-up for families whose members die in the ICU

The reader is redirected to the ANZICS document itself for more information, or to the RACP response for some hot takes by anonymous physicians, or to the local page on futile and non-beneficial care which contains a summary.

With respect to conflict and disagreement, the documents have this to say:

• Prevent conflict:
  • Prevent disagreement by early, sensitive and proactive communication
  • Be present for all meetings with other specialities to reduce inconsistent messaging
  • Listen and empathise with the concerns of the other party
  • Explore expectations of treatment and improve their accuracy
• Manage existing conflict:
  • Offer more time for ongoing discussions
  • Seek a second medical opinion and present the medical consensus
  • Involve a third party as a mediator during discussions
  • Be willing to negotiate and compromise, including agreeing to a trial of treatment
  • Seek advice from the Guardianship tribunal to give for consent for palliative treatment, eg. where the patient lacks capacity
  • Seek senior institutional advice, including legal and ethical advice, from the hospital administration
  • Seek legal intervention from the Supreme Court to help resolve a disputed decision