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An Official American Thoracic Society Policy Statement: Managing Conscientious Objections in Intensive Care Medicine

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An Official American Thoracic Society Policy Statement: Managing Conscientious Objections in Intensive Care Medicine AMERICAN THORACIC SOCIETY DOCUMENTS An Official American Thoracic Society Policy Statement: Managing Conscientious Objections in Intensive Care Medicine Mithya Lewis-Newby, Mark Wicclair, Thaddeus Pope, Cynda Rushton, Farr Curlin, Douglas Diekema, Debbie Durrer, William Ehlenbach, Wanda Gibson-Scipio, Bradford Glavan, Rabbi Levi Langer, Constantine Manthous, Cecile Rose, Anthony Scardella, Hasan Shanawani, Mark D. Siegel, Scott D. Halpern, Robert D. Truog, and Douglas B. White; on behalf of the ATS Ethics and Conflict of Interest Committee THIS OFFICIAL POLICY STATEMENT OF THE AMERICAN THORACIC SOCIETY (ATS) WAS APPROVED BY THE ATS BOARD OF DIRECTORS,OCTOBER 2014 Rationale: Intensive care unit (ICU) clinicians sometimes have accommodating COs should be considered a “shield” to protect a conscientious objection (CO) to providing or disclosing individual clinicians’ moral integrity rather than as a “sword” information about a legal, professionally accepted, and otherwise to impose clinicians’ judgments on patients. The committee available medical service. There is little guidance about how to recommends that: (1) COs in ICUs be managed through manage COs in ICUs. institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient’sorsurrogate’s timely Objectives: To provide clinicians, hospital administrators, and access to medical services or information or create excessive policymakers with recommendations for managing COs in the hardships for other clinicians or the institution, (3) a clinician’sCO critical care setting. to providing potentially inappropriate or futile medical services fi fi Methods: This policy statement was developed by a should not be considered suf cient justi cation to forgo the 4 multidisciplinary expert committee using an iterative process with treatment against the objections of the patient or surrogate, and ( ) a diverse working group representing adult medicine, pediatrics, institutions promote open moral dialogue and foster a culture that nursing, patient advocacy, bioethics, philosophy, and law. respects diverse values in the critical care setting. Main Results: The policy recommendations are based on the Conclusions: This American Thoracic Society statement provides dual goals of protecting patients’ access to medical services and guidance for clinicians, hospital administrators, and policymakers protecting the moral integrity of clinicians. Conceptually, to address clinicians’ COs in the critical care setting. Contents Overview so in the ICU setting. This policy statement Overview was developed to help critical care clinicians, Introduction Intensive care unit (ICU) clinicians are hospital administrators, and policymakers Methods sometimes faced with situations in which evaluate and manage COs in the ICU they have a moral objection to providing setting. This policy statement provides: (1) Ethical Analysis of COs in Intensive 2 Care Medicine or disclosing information about a legal, an ethical analysis of COs in ICUs, ( ) professionally accepted, and otherwise recommendations for management of COs Recommendations 3 Key Components of Institutional available medical service. Such objections in critical care settings, and ( ) proposed “ Strategies to Manage COs in will be referred to as conscientious components of a model institutional policy ” Intensive Care Medicine objections (COs). There is considerable to manage COs in ICUs. Conclusions controversy about how to manage COs in Accommodating COs can promote general and little guidance about how to do valuable goals. Reasons to accommodate Correspondence and requests for reprints should be addressed to Mithya Lewis-Newby, M.D., M.P.H., Divisions of Pediatric Critical Care Medicine and Pediatric Bioethics, University of Washington School of Medicine, Seattle Children’s Hospital, 4800 Sand Point Way NE, Mailstop FA.2.112, Seattle WA 98105. E-mail: [email protected] This document has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org Am J Respir Crit Care Med Vol 191, Iss 2, pp 219–227, Jan 15, 2015 Copyright © 2015 by the American Thoracic Society DOI: 10.1164/rccm.201410-1916ST Internet address: www.atsjournals.org American Thoracic Society Documents 219 AMERICAN THORACIC SOCIETY DOCUMENTS COs include: (1) to protect clinicians’ that respects diverse values in the critical physicians, nurses, respiratory therapists, moral integrity, (2) to respect clinicians’ care setting. pharmacists, etc., at any level of training), autonomy, (3) to improve the quality of acknowledging that each discipline has medical care, and (4) to identify needed unique roles, responsibilities, and challenges. changes in professional norms and practices. Introduction However, the accommodation of COs may have negative consequences for patients, Intensive care unit (ICU) clinicians are Methods colleagues, and institutions. Reasons not to sometimes faced with situations in which they accommodate COs include: (1)tohonor have a moral objection to providing or This policy statement was developed by core professional commitments, (2)to disclosing information about a medical service a multidisciplinary expert committee using an fl protect vulnerable patients, (3)toprevent (1). For example, ICU clinicians may have iterative process. The ATS Ethics and Con ict fi excessive hardships for other clinicians or moral objections to disclosing information of Interest (ECOI) Committee rst convened ad hoc the institution, and (4) to avoid invidious about the option of withdrawing nutrition an working group composed of discrimination. and hydration, offering or providing palliative a subset of members of the ATS ECOI The following four policy sedation to unconsciousness, participating in committee. The need for additional expertise recommendations are designed to balance organ donation, or providing advanced life was evaluated, and national experts two ethical goals in the management of COs support to patients with a poor prognosis. In were invited to join the working group. in ICUs: (1) to protect patients’ access a recent survey of ICU clinicians, 27% of The full working group represented to legal, professionally accepted, and respondents reported acting “in a manner a breadth of disciplines, including adult otherwise available medical services; and contrary to his or her personal and medicine, pediatric medicine, nursing, (2) to protect clinicians’ moral integrity. professional beliefs” during the single-day patient advocacy, bioethics, philosophy, study period (2). In that study, the most and law. fi Recommendation 1 common circumstance cited by physicians The working group rst reviewed COs in ICUs should be managed through and nurses was providing treatment known relevant literature and existing policies institutional mechanisms rather than perceived to be excessive or overly aggressive. of other medical organizations. The content ad hoc by clinicians. Healthcare These moral objections will be referred of this policy was then developed through institutions should develop and implement to as conscientious objections (COs) and a 3-year iterative discussion-based consensus CO policies that encourage prospective are defined as objections to providing process consisting of face-to-face meetings, management of foreseeable COs and that or disclosing information about legal, teleconferences, web conferences, and provide a clear process to manage professionally accepted, and otherwise electronic correspondence. A writing unanticipated COs. available medical services based on committee drafted the policy statement, which a clinician’s judgment that to do what is was reviewed by the working group members Recommendation 2 requested would be morally wrong (3). This on multiple occasions and revised. The fi Institutions should accommodate COs in American Thoracic Society (ATS) policy policy statement was further modi ed and ICUs if the following criteria are met: statement provides clinicians, hospital ultimately approved by the full ATS ECOI (1) the accommodation will not impede administrators, and policymakers with committee. This statement then underwent a patient’s or surrogate’s timely access to guidelines for evaluating and managing COs. a rigorous peer review process, and ultimately medical services or information, (2) the This policy statement does not address review by the ATS Board of Directors. accommodation will not create excessive objections to providing medical services that hardships for other clinicians or the are: (1) illegal (e.g., objection to performing 3 Ethical Analysis of COs in institution, and ( ) the CO is not based physician-assisted suicide in states where Intensive Care Medicine on invidious discrimination. this is illegal), (2) clearly outside accepted medical practice (e.g., objection to One approach to managing COs is to Recommendation 3 prescribing antifungal therapy for a bacterial accommodate clinicians by exempting them Aclinician’s CO to providing potentially infection), (3) outside the scope of from personally providing specificmedical inappropriate or futile medical services should a clinician’s professional competence (e.g., services. Accommodating COs may achieve not be considered sufficient justification to objection to intubating a patient without certain valuable goals but also may have negative unilaterally forgo the treatment against appropriate training and credentials), or consequences for patients, colleagues, and the objections of the patient or surrogate.
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