Decision-Making Approaches Used to Limit Potentially Nonbeneficial Life-Prolonging Interventions.

Area of Science:

• Medical Ethics
• Clinical Decision-Making
• Health Policy

Background:

• Professional guidelines recommend shared decision-making or institutional processes to limit nonbeneficial life-prolonging interventions.
• Healthcare systems often default to life prolongation, creating uncertainty about clinician practices.

Purpose of the Study:

• To characterize the decision-making approaches clinicians use to limit potentially nonbeneficial life-prolonging interventions.
• To identify whether clinicians rely on recommended or alternate approaches.

Main Methods:

• Qualitative study involving in-depth, semistructured interviews with 101 clinicians (physicians, nurses, chaplains, social workers) across 3 academic medical centers.
• Interviews conducted between February 2018 and June 2022.
• Analysis developed a framework categorizing approaches as recommended or alternate.

Main Results:

• Six decision-making approaches were identified: informed choice, recommendation, stating a plan, not offering, not mentioning interventions, and invoking institutional processes for conflict.
• Clinicians reported challenges with recommended approaches (shared decision-making, institutional processes).
• Alternate approaches were used, but with reported interclinician/interhospital variation and ethical uncertainties.

Conclusions:

• Clinicians encounter significant challenges implementing recommended strategies for limiting nonbeneficial life-prolonging interventions.
• Some clinicians resort to alternate approaches not aligned with professional policy statements, highlighting a gap between policy and practice.