Prognosis-Based Definitions for Potentially Inappropriate Treatment: Still Flawed, If Not Futile

AbstractThis analysis of professional organizational policies regarding potentially inappropriate life-sustaining medical treatment (LSMT) focuses on the specific threshold criteria that policies apply for limiting LSMT, as well as when (if ever) override of patient/surrogate preferences may be reasonable. Our article offers a critical analysis of one influential approach, proffered by the Society of Critical Care Medicine, that applies a prognosis-based definition of nonbeneficial/inappropriate treatment to determine that ethical threshold. We observe that this prognosis-based threshold resembles rationing in important ways, though it pertains to settings where resources may not be limited. In doing so, the approach raises concerns similar to those that have been raised about rationing, including the potential for strong institutional or individual practitioner biases and for discrimination against those with severe neurological impairments and/or indefinite technological dependence. We conclude that such concerns are valid and may never be entirely unavoidable. They may, however, be ameliorated with policies that incorporate various conceptions of harm within the calculus of cogent "competing ethical considerations" that define potentially inappropriate LSMT.