Best interest standards do not correlate with the reality of physicians' decision making in life and death choices
- Correspondence to Antoine Payot
Department of Pediatrics, CHU Sainte-Justine, 3175, Côte-Ste-Catherine, Montreal, QC H3T 1C5, Canada;
Implications for nursing practice and research
■ Clinicians appear to take decisions relating to resuscitation and non-resuscitation that do not always adhere to the best interest standard used in clinical ethical guidelines.
■ Discrepancies between best interest valuation and the respect of families' requests not to resuscitate shows that shared decision making is lacking in most cases.
■ There is a need for a shared decision making process with all patients and surrogates.
■ Further research is needed to explore decision making in this context.
The best interests standard is widely used in clinical ethical guidelines to frame emergency medicine practice in the absence of guidance by patients or their family. It is at the heart of the beneficence principle1 and cited in many bioethical guidelines. However, little empirical data demonstrate as how such standards are used in practice or how clinicians actually make assessment of best interests for their patients when decisions need to be made about whether or not to initiate resuscitation.
Leventhal et al explored the concept of best interests in a triage situation. The authors used eight vignettes of incompetent patients of various ages, pathologies and prognosis; all were critically ill with potential neurological sequelae. Their age ranged from 24 weeks gestation to 80 years. Using these scenarios, an online questionnaire was sent to US neonatologists and high-risk obstetricians. Participants were asked whether resuscitation was in the patient's best interest and whether the physician would agree to requests for non-resuscitation.
In response to the question “would you intubate, resuscitate and consult intensive care for admission?” respondents stated that they would initiate resuscitation for every scenario except for that of the 80 year old. However, for all the vignettes, the intent to resuscitate exceeded the best-interest valuation. The scale of this difference was the smallest for the 2 month old with meningitis and largest for the 35-year-old patient with a brain tumour.
Responses to questions about deferring resuscitation at the family's request showed that respondents would only do so when the physicians thought resuscitation was not in the patient's best interest in the case of the 80-year-old patient. Similar but less-striking decisions were evident for the 13 year old with acute myeloid leukaemia and sepsis, and the 35 year old with a brain tumour. Further, when physicians deemed resuscitation to be in the patient's best interest most would not defer it at the family's request. An exception to this was in relation to the two neonatal scenarios where most respondents indicated that even if resuscitation was in the premature infant's best interest, they would forego it at the family's request.
The concept of best interest standard is primarily a juridical notion, which has been translated to the medical practice2 but is in fact, one of the basic principles of the Convention on the Rights of the Child.3 This article demonstrates that this standard is not being directly applied to medical practice. Further, it shows that there is no consensus among physicians about such a standard. This suggests that aspects beyond pure medical facts and prognosis of the patients are used by physicians to frame their decisions. It is of interest that in most cases respondent would not defer to a family's request for non-resuscitation except for the youngest patients. This suggests that collaborative decision making only occurs when surrogates and physicians share similar values. This also suggests that collaborative decision making is not occurring in most clinical settings.
The results also reveal that even if medicine is often presented as a solid science where decisions are made through evidence, in the clinical setting decisions are taken by humans who are also guided by different sets of values and perspectives and may not adhere to ethical decision-making frameworks. The appreciation of the best interest standard by clinicians may differ from their own values and from what they would choose for a patient. The age of the patient appears to have an effect on physicians' decision making with clinicians being willing to forego resuscitation at family's request more readily for younger patients (premature and newborn babies) even if resuscitation is seen as in their best interest. Further, physicians stated that they would not initiate resuscitation for the older patient (80 year old). Decision making in this context needs exploring further.