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Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee

Kon, Alexander A. MD, FCCM; Shepard, Eric K. MD, FCCM; Sederstrom, Nneka O. PhD, MPH, FCCM; Swoboda, Sandra M. RN, MS, FCCM; Marshall, Mary Faith PhD, FCCM; Birriel, Barbara MSN, ACNP-BC, FCCM; Rincon, Fred MD, MSc, MBE, FCCM

doi: 10.1097/CCM.0000000000001965
Special Article

Objectives: The Society of Critical Care Medicine and four other major critical care organizations have endorsed a seven-step process to resolve disagreements about potentially inappropriate treatments. The multiorganization statement (entitled: An official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units) provides examples of potentially inappropriate treatments; however, no clear definition is provided. This statement was developed to provide a clear definition of inappropriate interventions in the ICU environment.

Design: A subcommittee of the Society of Critical Care Medicine Ethics Committee performed a systematic review of empirical research published in peer-reviewed journals as well as professional organization position statements to generate recommendations. Recommendations approved by consensus of the full Society of Critical Care Medicine Ethics Committees and the Society of Critical Care Medicine Council were included in the statement.

Measurements and Main Results: ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient’s neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment. This definition should not be considered exhaustive; there will be cases in which life-prolonging interventions may reasonably be considered inappropriate even when the patient would survive outside the acute care setting with sufficient cognitive ability to perceive the benefits of treatment. When patients or surrogate decision makers demand interventions that the clinician believes are potentially inappropriate, the seven-step process presented in the multiorganization statement should be followed. Clinicians should recognize the limits of prognostication when evaluating potential neurologic outcome and terminal cases. At times, it may be appropriate to provide time-limited ICU interventions to patients if doing so furthers the patient’s reasonable goals of care. If the patient is experiencing pain or suffering, treatment to relieve pain and suffering is always appropriate.

Conclusions: The Society of Critical Care Medicine supports the seven-step process presented in the multiorganization statement. This statement provides added guidance to clinicians in the ICU environment.

Supplemental Digital Content is available in the text.

1Pediatric Critical Care Medicine and Healthcare Ethics, Naval Medical Center San Diego and University of California San Diego School of Medicine, San Diego, CA.

2Anesthesiology and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD.

3Center for Ethics, MedStar Washington Hospital Center, Washington, DC.

4Department of Surgery, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, MD.

5Center for Biomedical Ethics and Humanities, University of Virginia School of Medicine, Charlottesville, VA.

6Pennsylvania State University College of Nursing, Hershey, PA.

7Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA.

Disclaimer: The views expressed in this article represent the official position of the Society of Critical Care Medicine. These views do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, National Institutes of Health, Department of Veterans Affairs, Food and Drug Administration, or the U.S. Government.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Kon disclosed other healthcare professional organization activities (President-elect, American Society for Bioethics and Humanities), disclosed government employment, and disclosed serving as an expert witness. Dr. Swoboda disclosed other healthcare professional organization activities (Surgical Infection Society, American Association of Critical-Care Nurses, Society for Simulation in Healthcare, International Nursing Association for Clinical Simulation and Learning member). Dr. Marshall disclosed relationships with providers of healthcare services (Consult for National Institutes of Health, and Academic Health Centers on Issues of Clinical and Research Ethics) and other healthcare professional organization activities (Consultant, National Institute of Allergy and Infectious Diseases, National Heart, Lung, and Blood Institute, and American Society for Bone and Mineral Research). Dr. Rincon disclosed relationships with providers of healthcare services (Otsuka, Bard), disclosed other healthcare professional organization activities (Neurocritical Care Society, American College of Chest Physicians), and received grant support (Genentech Research Grant). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: kon.sandiego@gmail.com

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