Our ethics consult team meets monthly to review cases, provide support for ongoing cases, and self-educate. Here is what we are reading this month:

1. “Shaping Patients’ Decisions“, J. S. Swindell , PhD; Amy L. McGuire , JD , PhD; and Scott D. Halpern , MD , PhD, CHEST 2011; 139(2):424–429

Many physicians struggle to strike an acceptable balance between respecting patient autonomy and guiding patients’ decisions toward what is in their best interests based on their expressed values and long-term goals. Over the past 40 years, the ethical principle of respect for autonomy has gained primacy in Western medicine, but judgments about the appropriate dose of influence on patient decisions have been clouded by misconceptions about patient autonomy. In this article, we consider three such misconceptions with the goal of helping physicians to optimally promote their patients’ interests.

The authors claim that most patients are not autonomous. They lack at least one of the three components of autonomous action: (1) intention, (2) understanding, and (3) absence of controlling influence.

The authors cite several recent studies of patients, outpatients, and surrogates which suggest that they would prefer to have some decision making help from clinicians. Shared decision making is indeed making a comeback. At the ASBH conference in October, I attended a clinical ethics advanced skills workshops, which featured a long session on shared decision-making.

I am not sure I see shared decision making as in tension with autonomy. In fact, it may be a prerequisite for patient autonomy in many cases. But the cautions suggested by the authors are well wroth noting.

2. “Can We Improve Decision-Making for Incapacitated Patients?“, ANNETTE RID AND DAVID WENDLER, Hastings Center Report, Sept-Oct 2010

When patients cannot make their own treatment decisions, surrogates typically step in to do it for them. Surrogate decision-making is far from ideal, of course, as the surrogate may not know what the patient prefers or what best promotes her interests. One way to improve it would be to arm surrogates with information about what patients in similar circumstances tend to prefer, allowing them to make empirically grounded predictions about what their patient would want.

The authors identify 6 ethical goals of surrogate decision making:

1) promote the patient’s clinical interests;
2) enable the patient to control how he or she is treated;
3) provide treatment consistent with the patient’s preferences and values;
4) respect the patient’s preferences for how treatment decisions are made;
5) respect and help the patient’s family and loved ones; and
6) promote timely decisionmaking.

They then contend that these goals are often not met in practice. As is now typical of the literature (see above article), several cognitive biases and external imitations are identified which prevent surrogates from making good decisions for patients. After briefly canvassing a few alternatives to current practice, such as having ethics committees make decisions for patients, the authors recommend joint decision making.

3. “Determinants of Medical Expenditures in the Last 6 Months of Life“, Amy S. Kelley, MD, MSHS; Susan L. Ettner, PhD; R. Sean Morrison, MD; Qingling Du, MS; Neil S. Wenger, MD, MPH; and Catherine A. Sarkisian, MD, MSHS,

Conclusion: Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics.

Of particular interest is this finding:

These data suggest that patient preferences, as documented in living wills, are poorly correlated with treatment delivered, which is consistent with other published data (16, 46–48).