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Why are some doctors so aggressive about withdrawal of care?

Why are some doctors so aggressive about withdrawal of care?

Here is a common scenario in the surgical ICU.  An older patient is admitted after significant trauma or a head bleed. The patient is intubated and minimally responsive.

It is the start of a new week, which means a new attending comes on board.  This attending has the reputation of being very “aggressive” about transitioning patients to palliative care.  He holds multiple family meetings  in order to convince the family that we have run out of treatment options and the best next step is withdrawal of care. But he will never use the word “withdrawal of care.” Instead he says that we are changing the goals of care, or the direction of care. The family’s hope for recovery is slowly chiseled away until they too believe there is no hope and they agree to compassionate extubation. The patient undergoes extubation and expires soon afterward.

I’ve seen this scenario multiple times and I have mixed feelings about this.  If a patient has endured an injury that studies show have a close to zero chance of recovery, I am on the side of the physician and will move to get the family to understand this — and I like to think I do this in an empathic manner. If however, studies show that there is some hope, I don’t see the reason why we as physicians need to force patient’s families into withdrawing care before they are ready.

I know what you’re thinking. That is the reason why health costs are so high. And I agree with you. But I think there needs to be some balance in this.  When the neurosurgery team wants to continue treatment, but the SICU team wants to withdraw, you know we have a lot of work to do in terms of figuring out a better protocol for determine who should be transitioned to palliative care. When one attending wants to continue management, and the next attending who comes on service wants to withdraw care, you know that physicians are making these decisions based on personal biases.

I think in the end though, we need to remember to approach our patient’s families with compassion and patience as we discuss withdrawal of care options. I acknowledge too that we also need to think about the financial consequences to the family and society for treating patients who will have poor outcomes regardless, but this should come second to the patient and family’s wishes.

My question to you: How trigger happy are you in pulling out the palliative care card?

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