Chapter 8: An Approach to Decisions About Clinical Interventions

Introduction

Medical interventions might allow accurate diagnosis and effective treatment, but they might also be applied when their benefit is questionable or when patients would not want them. Physicians, therefore, must try to avoid two types of errors: withholding potentially beneficial tests and therapies that the patient would want and imposing interventions that are not beneficial or not wanted.
This brief chapter presents an approach to decisions about clinical interventions. The general approach to ethical issues in Chapter 1 can be adapted to such decisions (Fig. 8-1). The key questions are as follows.

Is the Intervention Futile in a Strict Sense?

Sound ethical judgments require accurate medical information. Physicians are under no obligation to provide interventions that are futile in a strict sense (see Chapter 9).

Does the Patient Have Adequate Decision-Making Capacity?

This is a crucial branch point in decision making. Chapter 10 discusses how to determine whether a patient lacks decision-making capacity.

If the Patient is Competent, then What is the Patient’s Informed Decision?

Competent, informed patients may refuse medical interventions (see Chapter 11). Patients frequently lack decision-making capacity when decisions about medical interventions must be made. If the patient lacks decision-making capacity, then two additional questions need to be posed.

If the Patient is Not Competent, then Has He or She Given Advance Directives?

Clear and convincing advance directives should be respected (see Chapter 12). In the absence of such advance directives, decisions should be based on what the patient would want or what is in his or her best interests (see Chapter 12).

If the Patient Has Not Clearly Indicated What He or She Would Want Done in the Situation, then Who Should Serve as Surrogate?

Generally, the surrogate should be a person designated by the patient or a close family member (see Chapter 13).

This book then considers disagreements between doctors and patients over medical interventions. Chapter 14 analyzes insistence by patients or surrogates on interventions that physicians regard as inappropriate. Chapter 15 discusses conclusions about life-sustaining interventions that are commonly drawn but that prove misleading on closer analysis. Chapter 16 discusses how ethics committees or ethics consultants can help physicians resolve ethical dilemmas.

Next, this book analyzes life-sustaining interventions in specific situations. Chapter 17 discusses Do Not Resuscitate (DNR) orders. Often, discussions about DNR orders are the first step in a comprehensive evaluation of the goals and plans for care. Chapters 18, Chapters 19, Chapters 20, 21 discuss physician-assisted suicide, tube feedings, the persistent vegetative state, and the determination of death.

Legal issues are then presented. Chapter 22 analyzes landmark legal cases that have dramatized dilemmas about life-sustaining interventions.