How We Limit Non-beneficial Life Sustaining Treatments: Jason Batten, Liz Dzeng, Teva Brender

Eric 00:29

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:33

This is Alex Smith.

Eric 00:35

And Alex, today we’re going to be talking about how we limit potentially non beneficial life sustaining treatments. Who do we have don to talk to us about this?

Alex 00:44

Today we are delighted to welcome Jason Batten, who is a cardiothoracic anesthesiologist, critical care doctor and researcher at UCLA. Jason, welcome to the GeriPal Podcast.

Jason 00:55

Thanks so much for having us on

Alex 00:56

And we’re delighted to welcome back Liz Dzeng, who is a hospitalist, sociologist and ethicist at UCSF. Liz, welcome back to GeriPal.

Liz 01:05

Thank you.

Jason 01:06

It’s great to be here.

Alex 01:07

And a welcome back Teva Brender, who is a hospitalist and researcher at UCSF who is going to join our pulmonary Critical care fellowship here at UCSF next year. Teva, welcomed back to GeriPal.

Teva 01:19

Thanks for having us.

Eric 01:21

We’ve got a great show. Liz and Jason published a paper in JAMA Network Open 2026 titled Decision Making Approaches Used to Limit Potentially Non Beneficial Life Prolonging Interventions. But before we jump into that article and all about the topic, Jason, do you have the song request?

Jason 01:40

I do. We requested Wicked Game by Chris Isaac.

Eric 01:45

Chris Isaac. Was that 1990? I’m trying to pinpoint the.

Jason 01:50

I think it’s even older.

Eric 01:51

More than that. Oh my. Why’d you choose Wicked Game?

Jason 01:55

Well, first of all, it’s super catchy and has been, you know, remixed and covered a hundred times. So it’s a great song. But, you know, this paper is really focused on when patients and families want things that clinicians believe are bad for them. And I think for me that was the hook. Like wanting something that’s bad for you is obviously covered a lot in music. And so this is a really great song.

Teva 02:18

Love it.

Alex 02:18

Love that tie in. I think Chris Isaac’s a San Francisco musician. Is that right?

Eric 02:23

The song was recorded, I just looked it up in San Francisco, 1989.

Alex 02:28

89. Wow. Okay, here’s a little bit.

Alex 02:40

(singing)

Eric 03:37

Wonderful.

Jason 03:38

That was great.

Alex 03:40

I love that song. Thank you, Jason. That was a lot of fun.

Eric 03:43

Singing Chris Isaac, born in Stockton, California. Okay, we’re not talking about Chris Isaac here. We’re talking about wicked games, Teva.

Alex 03:52

Yeah, the wicked games that physicians play.

Eric 03:54

Why did you choose this topic? Just to give you a background. So we got an email from Teva suggesting that we actually talk about this topic in this paper. Teva, why did you email us?

Teva 04:07

I was inspired by your podcast on slow codes and the ethics of doing a slow code, and there were great arguments for and against. And I thought, hey, I know a couple people who’ve done some great research on this sort of thing and who have shown the different decision making frameworks that clinicians use in the real world. Not these highfalutin ethical principles. But how are clinicians doing this on the ground? And I thought Jason and Liz would be great to speak about this.

Eric 04:36

That’s awesome. Do you see this, like, on the ground, Teva, these different decision making frameworks?

Teva 04:38

Yeah, all the time.

Eric 04:44

Can you give me a couple of examples, like, obviously not a specific patient, but like something dialysis…

Teva 04:48

I think, where we know that we could do dialysis and you’re not sure who the nephrologist on service is because you know that some would offer it to anybody and some would offer it would actually have some limits to it. And so you ask yourself, am I going to bring this up to the family when we know it’s not going to benefit them, or is it just going to cause them more angst and distress to bring this topic up when, hey, you could turn around and ask the nephrologist, they wouldn’t even offer it anyway. So I’m not saying that I necessarily employ one or all of these strategies, but you see this happen not infrequently in the icu.

Jason 05:27

Yeah.

Eric 05:28

Jason, why did you get interested in this topic?

Jason 05:32

Well, I was actually a clinical ethicist, you know, before going to medical school. And I just remember one of my central questions after that period was, when do doctors get to say no? Because, you know, I just frequently consulted for these, you know, absolutely bananas. ICU goals of care conversations that, you know, had progressed far into treatments that physicians felt were non beneficial. And you Know, I’ve just sat in those conversations for years now, first as the clinical ethicist, then as the med student, then resident fellow, and now as an attending, and recently actually as a family member.

And I just thought it was really interesting how this dynamic and this challenge sort of recreates itself, you know, in hospitals across the country, ICUs across the country. And there’s just a lot of. A lot of tension there. And I think as I, as I have observed over the years, I started to see more and more examples of decision making approaches that didn’t actually conform to, you know, what I knew as an ethicist to be, quote, unquote, the right answer. So I was very curious to explore that. And I was just very lucky to work with Liz because Liz, as you know, is this incredible sociologist who has the most amazing data sets in the world.

I am convinced, you know, just like these awesome interviews where people really talk about how they deal with these challenges. And I thought there is a great paper here if we can actually, you know, excavate this data out of this interview data set. So it was just a lot of luck that Liz is my research mentor.

Eric 06:53

And Liz, for you, the same question. What motivated you to think about this topic?

Liz 06:58

Such kind words, Jason. So I’ve actually been very interested in this more broadly, really ever since I did my residency, which was, you know, a little bit ago. And I was at an institution in New York that had certain policies that were part of the state laws that influenced the way that we made decisions. And so I’m just, I’ve just always been really interested in how policies shape how we make decisions and the culture of an institution. And actually, just like thinking about this right now, I remember this really tricky situation that we had with family and actually the palliative care consultant, Craig Blinderman, who’s wonderful there, he introduced the topic of informed dissent.

And I remember that really, like, made had some challenges in our, in our team. There were some people that were like, what? I can’t do that. And other people, they’re like, oh, yeah, that makes a lot of sense. So even, you know, as a resident, that the first time the informed assent, which is, you know, one of the approaches that we were talking about in this paper that just created a lot of discussion and tension and conflict in the group, you know, just in terms of what to do. So it’s just something I’ve been very interested in for quite a while.

Eric 08:06

And then tell me about this data set that we just heard about.

Liz 08:10

Yeah, so this is, I guess, you could call it a secondary data analysis, although it’s really sort of taking in the primary data analysis that we did. So I’ve been actually doing this study for quite a while. I think it’s been almost a decade at this point where I interviewed people across the health care system. So not just physicians and nurses, but also staff administrators, healthcare leaders at three institutions in the west coast of differing intensity of care.

So looking at the Dartmouth Atlas of High, Low and Medium Intensity for End of Life Care, so you know, whether or not there are people that go to the ICU more at that hospital versus not near the end of life Medicare expenditures near the end of life. And so looking at differing intensities of end of life care and trying to understand through deep, rigorous ethnographic methods why there may be differences in the institutional cultures, policies, structures that influence the intensity of end of life care at those institutions.

Alex 09:14

And just to get too researchy, because most of our listeners are clinicians, not researchers. And why qualitative research for this particular issue. Anybody can take that.

Jason 09:26

Yeah, well, I’ll jump in because it’s dovetails to what I almost interrupted you to say, which is, you know, what’s great about this data set is if you look at, you know, the ICU literature, looking at decision making and communication around limiting life sustaining treatments, which has obviously been, you know, a topic of interest for, you know, two decades at least.

Now a lot of it focuses on the goals of care conversation where we sort of take the family into the conference room and sit down because that’s a really convenient time to record things that really limits actually your interactions. And as an intensivist, I’ll just say some of the most important interactions happen, you know, out in the hallway when you’re kind of informally walking through a room checking somebody’s vitals who’s unstable.

And, you know, Liz’s approach of interviewing people across their experiences allows you to capture data not only what clinicians report that they do, but also what other staff members observe that those same physicians do in context outside of the goals of care, you know, conversation. And so I felt like that was actually really key. And as far as I know, that data is not captured in any other, you know, extant form of data. You know, and to the quantitative people out there, I’ll just say, like, it’s certainly not something that’s going to be in a quantitative database at all.

Right. Because much of this is happening, you know, in a conversation in the hallway that’s never recorded anywhere, much less recorded in some kind of quantitative fashion that can be, you know, metricized and have a stats, you know, analysis done on it. So I think qualitative ethnographic data is, is really the only way to go if you want to study these decision making dynamics on the ground.

Alex 10:54

Yeah, I like the, the saying, some stories are better told with numbers and some stories are better told with words. This is the type of story that’s better told with words and qualitative data. Liz, go ahead.

Liz 11:07

And, and just to add on to that, what I really love about qualitative research is that it’s not just sort of giving you a sense of what’s going on in the hospital, but it’s giving you a sense of what people are thinking about it and how people’s perspectives on what they’re seeing influences each other, influences the institution, how that sort of in aggregate then influences the culture and all these different interactions. Like we are agents in the hospital that we work at and you know, we interact with patients and everything.

And so just hearing the richness of it and you know, clinicians and you know, all the people that I interviewed, they have such deep understanding. You know, it’s like they really understand what’s going on and they’re so you can really have a good conversation with them and they really open up. And so I think you can get a lot of nuance that you really can’t get in quantitative research through qual research.

Eric 11:55

And how did you ask about like the. So how do you make decisions around limiting potentially non beneficial life prolonging interventions? Like did you just ask that question? Do you have to define what potentially non beneficial life prolonging interventions are?

Liz 12:11

Yeah. So this study really was under, interested in understanding how people, you know, make decisions, communicate how they sort of experience care at the end of life. And so, you know, there may be some questions about that particular topic, but it’s really a lot broader than that. You know, I actually the study was focused on people with advanced dementia because I think that’s a really important case, you know, there. And it’s also like a little bit clearer than say other things where there’s a lot more uncertainty around it.

You know, there is more data around for patients with advanced dementia that the risks may outweigh the benefits of intensive care admission or life sustaining treatments. And so I really just ask questions broadly and then, you know, as the conversation goes on then we might broach on some of those topics. But you know, it’s broad. It’s a broad conversation and it really goes in the direction that People want it to go. It’s like an organic conversation.

Eric 13:05

And then anything else. Before we talk about the results, what did you find about how they make decisions that would be helpful to set the groundwork for this article? Jason?

Jason 13:15

Yeah, I think, you know, one other thing, a lot about the sort of the quality of the data that made this study really helpful, and this is, you know, unique I think, to the way Liz approaches the interviews is she really does get into people’s ethical frameworks. You know, why do they think it’s okay to approach a decision one way or another? And that’s really important because a lot of what this paper is getting at is, you know, what are, what are clinicians actually thinking when they’re taking these alternate approaches that actually aren’t supported by policy statements. And so I think understanding the ethical framework that individual physicians have is actually really important.

You know, and I think the last thing I’ll say, my favorite part of the data is just the stories of non beneficial care that come out in these data sets, like just these insane situations, you know, of conflicts with family, conflicts with physicians. And for me it was, it was so reassuring in a way to see that like this is a problem not isolated to the experiences that I’ve had as a clinician or as an ethicist. This is really a problem that’s a major issue across US Healthcare, at least at the academic medical center studied. And it’s something that really weighs on people. And so Teva’s paper, which he published actually before this one, is on moral distress from the same data set, but a different way of analyzing and looking at the interviews.

And it was just really, I think, reassuring and also like raised my interest in this topic just to see, I think, how bothered people are by these cases. People would, you know, report a terrible case that happened like years ago and they tell it to you like it happened yesterday. And so I think the data set is just like really evocative in that way.

Eric 14:53

And Teva, is that what your paper you published on? Was that on the moral distress of this? Tell me about that.

Teva 15:00

Yeah, so we looked at moral distress related to potentially non beneficial life sustaining treatments. And I think again, one of the, of the strengths of the way that Liz does her interviews is she doesn’t define potentially non beneficial life sustaining treatments. She doesn’t define shared decision making. These are people speaking in their own words and grappling with the difficult decisions and the nuances in real world clinical practice. And so I think you see folks being very frank, very honest and Very open. And the only way to really pull out these different decision making frameworks that Jason will talk about shortly is because clinicians are just bearing their soul and they’re just talking about these very visceral experiences.

Eric 15:39

And what kind of moral distress did you see?

Teva 15:41

Well, there’s a lot of moral distress around potentially non beneficial licensing treatments. We described like the different institutional structure on culture factors, factors that exacerbate and the different structures that mitigate moral distress. So unsurprising is like palliative care, a culture that’s supportive of palliative care helped mitigate clinicians moral distress. And then this default trajectory towards high intensity treatments, conflicts with families, conflicts with other clinicians really exacerbated moral distress.

There was also some interesting things about advertising and the reputation of the institution. So these are very prominent quaternary tertiary centers, academic medical centers, patients coming for that fourth line of chemotherapy, people coming for the transplant, people coming for ecmo. And that really creates an expectation that patients are gonna get intensive treatments.

Eric 16:36

And then for this study, Jason, we mentioned the framework that you used. Tell me about the framework.

Jason 16:43

Yeah, I guess I’ll talk about the analytic framework first, which was really key. So I mentioned as an, you know, in my prior experience as an ethicist, you know, sort of having some sense of what quote unquote, the right way to approach these situations are based on, you know, policy statements, legal frameworks.

Eric 17:00

What’s that?

Jason 17:01

Hospital policies, which I’ll right now, you know, but it basically boils down to, and, and we drew specifically from critical care society statements for this paper is there are things we called recommended approaches. And then everything else we put into the bucket of alternate approaches. So recommended approaches fall into two categories. The first is any kind of method that you use to reach a shared decision. So in other words, the family or the patient actually agrees with you to limit shared, to limit life sustaining treatments. And then when a shared decision can’t be reached, which is obviously a prominent issue in critical care today, the policies, they allow you to not offer only in cases of physiologic futility.

So that’s cases where a treatment has a zero percent probability of achieving its intended outcome. And so the examples in policy statements given are things like giving an antifungal for a myocardial infarction or EPR on a corpse, CPR on a corpse, EPR on a corpse. So those are very extreme examples, but they very clearly fit this idea of physiologic futility. And I think what our dataset really shows is like no one’s really struggling with families asking for antifungals for a heart attack. Right. What we’re struggling with is things like can we add the fourth vasopressor for shock that, you know, there’s no way out of anyway. And things where physiologic utility doesn’t necessarily apply.

And so what the guidelines recommend you do, if you can’t reach a shared decision and you’re not in the realm of physiologic utility is then you follow an institutional process. And that looks a little bit different at every place. But most, you know, hospitals all have some kind of utility process or medically ineffective care policy or, you know, something along those lines that allows you to shift out of the conversation between, you know, the clinicians and the patient family to involving the whole institution in some policy backed way.

And so those are the two recommended approaches is, you know, shared decision making or using one of these institutional policies. And then everything else we bucketed into this category of alternate approaches. What else, you know, are clinicians doing on the ground when they don’t think those recommended approaches are actually working for them?

Eric 19:12

And it feels like in real life we’re trying shared decision making first. That’s not working. And if we really feel like something is potentially non beneficial, we’re going to like an ethics committee. I’m just thinking back to our podcast on unilateral DNRs and how we think about that. But also in clinical practice, it’s usually after everything else has failed, we’re going to the ethics committee.

Jason 19:33

Yeah, a hundred percent. And our framework uses the words as the last resort.

Alex 19:39

So.

Jason 19:39

And I think one of the findings is people don’t even want to do that sometimes because they don’t think it’s going to work or they think it’s overly burdensome. You know, there’s a lot of reasons why people hesitate to pull the trigger on the futility process.

Eric 19:50

So they’re using some of these alternative ways, decision making approaches. What are the alternatives?

Jason 19:56

Well, just to summarize them real fast because I think there’s a lot of, you know, meat in each of them. Some physicians reported stating a plan to limit interventions. So this gets to what Liz brought up earlier about informed descent. But in that approach, the physician says, this is what we’re going to do. We’re going to stop everything and transition to comfort care. And doesn’t necessarily provide an option for the surrogate decision maker to object to that plan and doesn’t necessarily put other options on the table.

And so an important finding in this study is that that doesn’t actually match the original descriptions of informed dissent, which required that you stay in the realm of shared decision. And so by removing choice entirely, we found that people were actually deviating in some cases as they described this approach from, you know, the ideals of shared decision making. So that’s one.

Alex 20:47

So Jason, just to stick with that for a moment, the recommended approach is to say we could do this or we could do that. We’re going to do this.

Jason 20:57

Yeah. The recommended approach is to either explicitly offer the family an opportunity to defer to physician judgment or say this is the plan and offer an opportunity to object to the plan while making sure that they know there are alternate options on the table. That would be how you keep that strategy in the realm of shared decision making because you’re maintaining choice. Right, I see.

Eric 21:21

So let me ask you this because my approach is like, when I think about our palliative care consults, it’s always three steps. First is we just have a shared understanding of illness and prognosis. Then we talk about goals, like what’s important, what they’re hoping for, what they’re worried about. And then I offer to make a recommendation and then my recommendation, I’m not listing options, like if their goals are clear, like, I’m not talking about like dialysis and ECMO and all of this. If their goals are consistent with like getting out of the hospital, being at home, I’m saying this is what we should do. Does that sound okay? Which bucket would that fall into

Jason 22:00

or is it wicked? Well, I mean, I think what we found in the data, and this is why the analysis takes so long, is depending on how much detail you get from somebody, it’s actually quite hard to to bucket it. So sometimes you actually have to be in the room and I think talk to people about are you aware that there’s actually an alternate option? So, and even in the description you gave, which say it’s actually analogous to some of the interview descriptions we got, we couldn’t say definitively which category this particular instance fell into.

And so yours I might have bucketed as, you know, making a recommendation or stating a plan, interventions, you know, so it would really to me depend, like, did that family know that another option was to continue with the life sustaining treatment? And were they aware that they were making a choice to defer to your recommendation with other alternatives on the table? Right. I don’t know that from what you just said, you may have more insight into that. But I think clinicians Actually often don’t know exactly what’s going on in the other party’s head is they’re kind of engaging in these very difficult conversations.

Teva 22:57

And I think one of the strengths of this paper and this framework is to help clinicians understand where am I on this spectrum of more or being more or less directive with patients. It’s not to say that, like Jason’s saying, different clinical situations sort of overlap, but it’s helpful to think to yourself, what am I doing in this situation? And should I make an explicit decision to move in one direction or the other?

Alex 23:21

Okay, so we got through one. Well, oh, well, we may come back to it. What are the other alternative approaches?

Jason 23:29

Yeah, so to be brief, because I think these ones are actually simpler. You know, one step of increasing guidance past that is, is to just not offer something to be explicit about it and, you know, to hold that line in the sand, even over family objections. So this would be the physician who says, you know, I’m not going to offer dialysis. And family objects and physician just says, sorry, and then doesn’t actually invoke the, you know, futility process, just says, no, I’m not going to do it, and at some point exits the conversation.

Eric 23:57

Okay, we’re just going to. We are drawing the line. Yeah, that seems simple. That one I get, like, we are not going to offer dialysis, and we’re being explicit with it. And then what’s the last one?

Jason 24:11

The last one, which is kind of my. My favorite because it gets at this, like, secret conversations in the hallway that I mentioned earlier, is not mentioning interventions, you know, and I think we all probably, as trainees, you know, in. In medicine team rooms or, you know, whatever specialty you trained in, had experiences where you discuss an intervention in the team room that, like, theoretically, you know, could be indicated in a situation. And everybody makes an agreement like, nobody say this to the family. And so sometimes, you know, the decision is made to not involve the consultant who offers that intervention. Like, not involve the nephrologist, as Teva brought up earlier. And that way you don’t have to worry about that consultant coming in and putting something on the table that you really don’t want to have on the table.

Eric 24:54

So acts of omission.

Alex 24:56

That’s Eric’s approach. I think that’s Eric’s approach, not offering the intervention because it doesn’t align with the patient’s goals.

Eric 25:04

But isn’t that shared decision making? Like, I am not when I think about shared decision making. We’re not offering 3, 13 million things to Patients and having them choose, I would say that’s not shared decision making. That’s just giving them a list of options. They don’t even need a doctor for that.

Alex 25:21

Yeah, it’s like a paralysis of choice.

Eric 25:23

Yeah. And then we’re actually defaulting to do everything to keep them alive. Because if you have too much choice, you’re not going to choose anything versus, like, we’re omitting things all the time. Alex, when was the last time you talked to a patient about ecmo?

Alex 25:39

I haven’t.

Eric 25:40

He’s admitting every single time. Alex is going to number five.

Liz 25:45

Yeah, I mean. Yeah. I mean, that’s like the really, you know, we had so many conversations about this, this spectrum and that figure that we have in. In the paper. And it. We’re not, you know, we’re not saying, like, this is bad or this is good. It’s like all of these, like, are potentially reasonable approaches. You don’t, you know, offer to, like a liver transplant for a broken leg. You know, like, there are things that just don’t make sense for that situation. But I think the other nuances, like, Eric, I, you know, as a palliative care physician, I know that you’re engaging in shared decision making. You’ve observed and had a discussion around their goals and values, and you’re making a clinical judgment based on that. I think there’s also variation in how people are doing this.

And so, you know, there’s also a lot of nuance and skill in how people are approaching these conversations. But I think the broader point is that which, you know, is one of the motivations for, you know, I know Jason and myself, is that the guidelines are very specific about, as you said, don’t do CPR on a corpse or no antifungals for myocardial infarction. But there’s such a broader range for how we’re having these conversations and the frameworks that we need to explore this. And so without clarity of guidelines and understanding that the real world situation is not that we’re just discussing, like CPR and a corpse, but these broader. These are so many decisions that need to be made and are made with shared decision making with the family, we need to have clearer guidelines, discussion, and transparency around what we’re doing.

Eric 27:19

I love this too, because it brings up. We have a lot of treatments that I think many of us consider bridge treatments like ecmo, bridge treatment, cvva, so continuous dialysis in icu, like a bridge treatment. And then when we don’t view them as bridges to anywhere. So this Bridge to nowhere. We ask ourselves, like, what are we doing here? Where are we going here? Do we even offer it? Because it’s a bridge to nowhere, which is not technically futile based on what you said, because it will make them live longer in an icu, but there’s just no way to ever get them out of the ICU. So I struggle. I every. When I read your article, I thought about all the cases where it’s this bridge to nowhere argument. And, Jason, you deal with ECMO all the time, right?

Jason 28:11

Yeah. Well, before I talk about ecmo, because I think ECMO is just kind of like the cutting edge, leading edge, you know, instantiation of this problem. You know, I do just want to take a step back and say I feel like what the last, you know, three minutes of this conversation has really illustrated is this tension between the lived reality on the ground of clinicians navigating these decisions and the ethical frameworks. Right. And I think all of the things we just bumped into are exactly the things clinicians bumped into in our interviews and exactly the things that we bumped into in our data analysis.

And so I, you know, I just really want to take it back to, like, what’s the point of this paper? But, like, part of the point of this paper is, like, we actually need better frameworks that help us think about these things. Because right now, you talk to clinician A, they will say one thing, and you talk to clinician B, they will say something. And they are directly contradictory. Right. About how the ethical framework applies or whether we have to offer something. And that lack of uniformity and that lack of a shared framework, I think, is actually an issue in itself. And so there’s just a real need, I think, for more discussions.

And our goal is not to kind of, like, take down these guidelines. You know, like, these guidelines were the first critical care policy statements, you know, really made in some of these really tricky areas. We needed them. Right. They were a foundational step, and now we have to, like, keep going. And the only way to do that is to really, you know, see how they’re functioning on the ground. And so this article was one. One step towards that.

Alex 29:34

Yeah. And I noticed you didn’t you call them alternative frameworks. You didn’t call them wicked frameworks.

Eric 29:39

Yes.

Alex 29:41

So there was no, like, judgment associated with these alternative frameworks, though. They do not, as you pointed out, comply with the guideline approaches as recommended. And I love that you mentioned the Slow Code podcast. I think, Teva, at the beginning, like, that podcast, just show that, you know, this is Happening. So many clinicians are seeing slow codes, been involved in a slow code. We need to rethink the ethics behind it because that’s what’s happening on the ground and rethink our frameworks. And this is like the qualitative counterpart to that article that goes in depth. Go ahead, Liz.

Liz 30:20

Yeah, and you know, one of the things that we invoke in the discussion is the concept of workarounds. And you know, slow codes is one, one sort of demonstration of workarounds. You know, they’re having trouble with like the way that guidelines or policies are what they’re being asked to do. And so they do a slow code. And so, you know, what we’re saying here is that, you know, the guidelines are very strict or very limited in terms of what they’re guiding.

And so, you know, there’s so much variation and workarounds. And so, you know, and as we discussed before, you know, Eric, using one particular alternative approach is very different from maybe, you know, somebody else, a first year intern, using that same alternative approach. And so can we actually expand on the guidelines to help provide more guidance and more, more of a framework for people to think about these different approaches?

Teva 31:16

If I can jump in, just say two quick things. One, I think it matters how you get to the decision. So Eric, I’ve worked with you. I know how excellent you are in these discussions and you really are able to make a very informed recommendation based on their goals and values. And that doesn’t always happen. And the second point I’d like to make is that I want to. I think most clinicians have good intentions and the reason that they’re not going to the institutional protocols for non beneficial treatments is that it, it, it ruins the therapeutic relationship you have with the family. And so clinicians are using these workarounds as well to maintain that relationship, to maintain that therapeutic relationship, to not alienate families. And they think that they’re doing a good thing by doing this. Yeah, it’s more or less with others.

Eric 32:01

Well, Liz, let me ask you this because I wonder if there’s more than in going to the ethics committee or some institutional committee, because there’s probably a lot of cultural differences depending on which hospital you are. Some ethics committees, they seem to be run by the legal department, just not wanting to get sued, it feels like. And some ethics committees are all, yeah, let’s just have one member of the team give the okay for the unilateral dnr. Like there seems to be a huge wide variation and the desire to go to ethics Sometimes also changes based on do I think they’re going to help at all? Do you get that sense, too, Liz?

Liz 32:37

Yeah, so. So I think that that’s a really good point. There’s so much variation, and even in the three institutions that, that we interviewed at, there’s huge variations in the ethics committee or, you know, whether or not their first port of call is to palliative care rather than ethics committees for these sort of challenges. And so, you know, some of my other work is really thinking about, like, how do these support structures like ethics or risk management or hospital leadership, how does that, how do they either help or make it more difficult for people to make the right decisions or to work with the families to achieve a consensus around decision making.

And so I think that that is something really important to consider. And having a better framework, I think, is also helpful for how can we actually make ethics committees more supportive or institutional policies more supportive around this?

Eric 33:28

All right, I’m gonna go back to the framework then. So, Jason, because Teva said some very nice things about me as a physician, but, like, to be honest, I really like this framework because I do think that I probably do all of them and maybe all in the same meeting. So how much of this is like, you know, the stages of grief initially thought, like, you go through each stage as a step until you finally enter acceptance. And we’ve learned that you probably actually feel everything all at once.

How much of this framework is happening kind of all at once. During these shared decision meetings, I may be giving some options, like hospice versus non hospice. I may be omitting things left and right. Like, I’m not talking about ECMO or pressers. I may be doing shared decision making, figure out, like, what’s important to them to make some recommendations and maybe asking about, like, I, I may, I think I am probably using a lot of these steps all at once.

Alex 34:25

Oh, yeah, me too. I use all of these.

Jason 34:28

Yeah. I mean, I think that was our experience in data analysis. And that was also my experience, you know, being an intensivist while doing this study was, you know, sometimes I’m doing three at once. You know, sometimes I’m just doing one. And it really depends on the situation. And I, you know, I think what I really took away from the interview data and then using that as a launching pad to reflect on my own practice, you know, where I deal with these conversations on a day to day basis, it just how many pieces of information I’m taking in as a clinician to make a very, you know, contingent and often Kind of risky judgment about like which approach I think is going to work with this family member, you know.

Cause some people, I think the right, the thing that will work best for them and guiding them, you know, away from aggressive treatment and you know, towards comfort care is really to just lay out every single choice and really explain it. Right. Like approach one. And for other people, just based on my interactions with them and based on some contextual details about the situation, I may feel that, you know, stating a plan is more appropriate and sometimes I might state a plan that implicitly omits a whole bunch of other things. Right. And so then I’m doing, you know, approach three and approach five. And then only if they ask and push, well then I, you know, invoke, you know, approach four and like say no, this is my line in the sand. I’m just not willing to do that to your loved one.

Yeah, I think, you know, it’s, it’s highly complex I think is what I took away from it, which is why, you know, it’s, it’s a skill, right. It’s a skill to have these conversations. And some of what this framework does is just illuminate how many things are going on on the decision making and ethics side of these conversations that I think had previously sort of been under the surface. Especially the degree to which those moves that I think very experienced folks are making often do not necessarily comport with, you know, critical care policy statements. Because I think earlier work. Just one other thing, Liz’s earlier was really interesting in that she found that the more senior clinicians are, the more comfortable they are, for example, not offering non beneficial CPR at the end of life. So something.

Alex 36:29

So without having read the guidelines from Society of Critical Care Medicine, I’m going to attempt to mount a spirited defense of keeping the guidelines the way they are and the reasons for the recommended approaches. Like, you know, have we really gotten away from the days of the doctor knows best or is this really medical paternalism in palliative care clothes? And if you ask people with serious illness or surrogates of people with serious illness if they want to be offered a choice when it comes to potentially non beneficial life sustaining treatment because it’s potentially beneficial as well, they will probably say yes.

And I would guess that there are studies that back them up. And I know Doug White’s done some studies around offering recommendation and that not all, you know, surrogates or seriously ill patients want or appreciate a recommendation, you know, and they worry about the source of the recommendation and the reasons behind the Doctor’s recommendation and sometimes with good reasons given, for example, legacies of racism, unequal treatment, persistent inequalities in care. And so they’re really important reasons that we should and ought to engage patients in shared decision making in every single instance. And when that fails, going to the institutional policy and not doing these shortcuts, workarounds which are ethically problematic.

Teva 38:01

And by shared decision making, do you mean listing all 27 options? Because I think that’s the crux.

Jason 38:06

Right?

Teva 38:06

What is good shared decision making?

Alex 38:09

Yeah. And I don’t think you need to list all 27. You don’t have to say like you’re gonna omit some, or we, you know, you like, you know, or this antibiotic or the antibiotic. But I think that you violate the spirit and the intent of the guidelines when you’re talking about leaving out major, major potential life sustaining treatments options.

Teva 38:34

Well, I think that’s fair criticism. Sorry. And, but, and this is a good place for Liz to jump in, talking about the society we live in, the broader culture, the national culture, medical culture, and I think it’s important to realize that the decisions that patients and families are making are not, they can’t be extracted from that broader context. And the default that we have in this country towards high intensity treatments.

Liz 39:00

Teva, you took the words out of my mouth. I, I, I think we were all probably thinking that, that like, that’s sort of how, you know, we start off the paper is that we operate in a default of high intensity treatments near the end of life. And like even that alone, that’s not necessarily concordant with what most people want. In fact, we know that most people don’t want to, you know, they want to die peacefully and around their loved ones and not, you know, hooked up to machines when it’s not going to work.

And so I think recognizing that actually we do operate within not just a society that has high intensity treatments is a default at high intensity medical centers, but also institutional culture and just the way that things operate. And so how do we help families? And another aspect of this is like the tremendous burden that face families have in trying to make decisions. And so when we offer potentially a false choice of like, you know, do we want all these different options when maybe they might not be helpful, how is that potentially harming the fa, the family as well?

Jason 40:03

Yeah.

Eric 40:04

And I also wonder what’s the role of the expertise of the physician? Like, will this achieve that thing that’s important to you? And also then what’s the role of just saying no and I wonder, like, if a surgeon’s listening to this podcast, like, like, oh, my God, internal medicine docs, family medicine docs are so in their head, like, we just say no. They will just say no to a surgery. They won’t give people options. You can’t go to the ethics committee and convince a surgeon to do a surgery. They are the masters of that. Or do we have something to learn from the surgeons, Jason?

Jason 40:39

Yeah, well, I mean, I didn’t say this at the beginning, but, you know, as an anesthesiologist, I sort of sit in the middle of the surgical decision making. And that was one of the things that prompted my interest in precisely this issue. Right. You know, and so just to contrast a few interventions, like ask a, you know, a palm crit person, like, would you feel comfortable walking into the room of a patient who’s desaturing where the family saying, please intubate this person. And, you know, even though you think it’s going to be futile, would you ever feel comfortable not putting the breathing tube down?

The answer is, I don’t think I’ve ever met somebody who’d be willing to do that. Right. They would put the breathing tube down and then sort it out afterwards without a very clear agreement and an advanced directive and, you know, all the things that we would expect. Whereas, like, for ecmo, you know, routinely when I’m on service, I walk into the room of a patient not doing well, and I say, no ecmo, and I call the surgeon, who may or may not agree with me. But if we both say no ecmo, then it’s a no go, right?

Eric 41:33

You’re not even talking about ecmo. You’re admitting it. It’s just not an option.

Jason 41:37

Yeah, we just say, nope, walk out. You know, and sometimes the primary team even pushes and we say no, and then we walk out. And it’s very, you know, that difference in decision making. People invoke all kinds of things, right? Some people will invoke, oh, because it’s a surgery. And the surgeons have metrics. So that’s why. Because they have metrics. And other people say, oh, it’s because ECMO is not standard of care. And so maybe that’s why. But actually, we don’t really know why. It’s just a cultural difference. Right.

Eric 42:04

It’s like continuous renal replacement CRT in the ICU is. I mean, whether or not you get it or not depends on what week and who’s the attending and whether or not they would do a potential bridge to nowhere.

Jason 42:20

And that’s some of the exploratory work we’re actually calling for is like, so there are these differences by intervention and by specialty. Like, is that legitimate, or do we need to hold everybody to the same standard? Right. And the other thing I’ll say is kind of lurking here, as we’ve talked about, well, are we listing all 27 options, or are we just listing the things that really matter? Right. And the way I have come to talk about that after doing this paper is like, everyone agrees you should sort of start with shared decision making, and that means putting all the reasonable options on the table.

And what we find is a lot of differences among physicians and how big that table is and how many options go on that table. Right. And some people just have a much smaller table and don’t think you need to mention and cannot offer much more things than other folks. Right. And so I think that’s some of the work here, is figuring out what kinds of things need to be put up for shared decision making and what kinds of things can be kept in the authority of physicians, so to speak.

Liz 43:14

Just to quickly add on to that is that, you know, given the technological imperative that we have in American medicine and the way that technology continues to progress, like, right now, ECMO is not standard of care, but, you know, like, the indications for that are increasing. And, you know, how. What are we. What is it going to look like in 10 years, 20 years?

Eric 43:31

You know, it’s going to be like dialysis. Right.

Jason 43:34

That’s a horrifying world. But potentially, yeah.

Eric 43:37

Unless, like, you’re okay with living in an ICU on an ECMO machine for the rest of your life, potentially.

Liz 43:45

I mean, chronic critical illness is increasingly.

Jason 43:48

Right.

Liz 43:49

So, you know, is.

Eric 43:51

Is another week alive in an icu. Who gets to decide, is that worth going through these procedures like ECMO? I guess my last question to all three of you, kind of lightning round, magic wand, like, I’m not going to go to policy. What should happen next? But if you were a clinician who just read this article, what would you want them to do differently or anything? After reading this article, I got my answer. I’d love to hear yours, Jason.

Jason 44:20

Yeah, I’ll go. So, you know, this article came out and many of my colleagues read it, and I think the misreading of it, which I would want to tell everybody about, was that, oh, so you’re saying all these approaches are good? Whenever I want, in spite of the very clear discussion section that says that’s not the case. And so my lighting around is like, definitely realize you are taking on some risks and stepping to some degree to ethically uncertain waters when you use the alternate approaches. So be careful, think carefully, and ask yourself, am I really doing what’s right for the patient, ethically acceptable?

Eric 44:52

So I can’t just look at the pretty picture.

Jason 44:54

Yeah.

Eric 44:55

Can’t just look at the pretty, Liz.

Liz 44:58

Yeah, I mean, I think that what I really want people to take away is just even thinking about their approaches in a conscientious way in a sort of. You know, I think a lot of people, they come into a family meeting, they’re like, okay, what are we going to say? We’re just like, kind of potentially just, you know, wing it. I mean, hopefully there’s more preparation than that, but, you know, just, like, being intentional about, like, what approach am I using? What is. What is the impact of that? What is the ethical thinking that that brings me to, that particular way of doing things?

Eric 45:25

That’s actually my. Like, that was my take home after reading this. I was like, man, I’m probably using a lot of these all the time without even noticing, and I should probably be mindful what I’m. What I’m doing. Teva.

Teva 45:36

Yeah, I agree. Be mindful of which approach you are going to use going into the conversation, and then be aware of what are the things the family’s going to say to me. What are the dynamics in the conversation that might make me choose to pivot

Jason 45:49

and adopt a different strategy.

Eric 45:52

Yeah, I love that, too. Alex. Anything from your standpoint?

Alex 45:56

I do think the guidelines need to be revisited and that when you get to a situation where many or maybe even most doctors are doing something different than what the guidelines say, then we need to attend to that. It’s not just, hey, you need to adhere to the guidelines. It’s time to revisit the guidelines.

Eric 46:14

Yeah. And really, I. We haven’t even talked about, like, how do we even define beneficial? Like, beneficial for what? For whom is living again a week alive in the icu? Is that beneficial? I think most of us doctors would probably say, no, that’s not beneficial to care.

Jason 46:29

I don’t know.

Eric 46:29

Is it beneficial for patients? Such wicked questions.

Alex 46:34

There we go.

Jason 46:35

There we go.

Alex 46:46

(singing)

Eric 47:43

I had the urge to join as the backup singer there [laughter].

Alex 47:52

It’s so good, so singable.

Eric 47:55

It is so singable. Well, Liz, Teva, Jason, thank you for joining us on this podcast. That was great.

Liz 48:02

Thank you. Thank you so much for having us.

Eric 48:05

And we’ll have a link to everything we talked about in our show notes. And thank you listeners for your continued support.

This episode is not CME eligible.

For more info on the CME credit, go to https://geripal.org/cme/