“No escalation of treatment” as a routine strategy for decision-making in the ICU: con

Excerpt

Bioethicists have long argued against making a distinction between the ethical acceptability of withholding versus withdrawing treatment [1]. The modern secular consensus was expressed concisely in a landmark 1983 report: “neither law nor public policy should mark a difference in moral seriousness between stopping and not starting treatment” [2]. Nevertheless, it is easier to endorse this principle than to apply it. There is no question that withdrawing feels different to families and clinicians because the temporal link between the decision and death imposes a sense of responsibility that is difficult to allay with intellectual arguments about causality [3, 4]. The concept of a “no escalation of treatment” order relies on this cognitive bias to overcome barriers to implementing a treatment plan that includes withdrawal of life-sustaining treatment. This order is used to declare that there will be “no escalation” of any treatment, neither starting a new life-sustaining treatment nor increasing the intensity of a life-sustaining treatment currently in use. A recent retrospective review of patients who died in a medical ICU found that a stunning 30 % of deaths had a designation of “no escalation of treatment” [5]. However, we believe that routine use of such a “blanket”, all-encompassing “no escalation of treatment” order is ethically confusing, if not unethical, and is often difficult to implement in a consistent and coherent way across the many ICU clinicians caring for a critically ill patient. More importantly, in most situations there are more effective alternatives. …