A proposed paradigm shift for surrogate decision-making in ICU
department or school: Graduate and Postdoctoral Studies
data provider: DSpace
degree campus: UBCV
creator: Byram, Adrian Cyrus
issued: 2019-09-17T13:18:42Z
issued: 2019
related degree: Doctor of Philosophy - PhD
degree grantor: University of British Columbia
description: Each year four million adults in North America require a surrogate to make decisions for them after being admitted to an intensive care unit (ICU). These decisions frequently involve the limitation of life-sustaining treatments. The current paradigm for making these decisions requires surrogates to rely first on any advance directives from the patient, then on the surrogate’s substituted judgment, and finally on best interests as judged by a reasonable person. Since this paradigm emerged 40 years ago, hundreds of research studies have revealed conceptual and operational deficiencies with it and have documented the harms it may cause to patients, surrogates, and medical professionals. The accumulated weight of these studies motivates the central research question of my dissertation: What shifts to the current paradigm for surrogate decision-making might alleviate its clinical and ethical deficiencies? I address this question as an interdisciplinary neuroethics scholar relying on the research methods of interpretive description and qualitative metasynthesis to organize the accumulated evidence into pragmatic recommendations. This work required three separate but linked studies. In Study #1 I mined research on surrogates’ experiences to identify factors that influence their decision-making. In Study #2 I synthesized research on surrogate-professional relationships to identify gaps and conflicts between the decision factors from Study #1 and surrogate-professional interactions. In Study #3 I analyzed all seven editions of Beauchamp and Childress’ Principles of Biomedical Ethics (1979 to 2013), charting the evolution of bioethical thought regarding incompetent patients, and linking these changes to the results of studies #1 and #2. The findings from these studies informed three changes I propose to the paradigm and practice of surrogate decision-making in ICU. My proposal integrates the decision standard of individual best interests, a standardized values portrait captur…
aggregated CHO: https://circle.library.ubc.ca/rest/handle/2429/71698
note: A PROPOSED PARADIGM SHIFT FOR SURROGATE DECISION-MAKING IN THE ICU by Adrian Cyrus Byram B.Sc. (Honours), The University of Toronto, 1967 M.Sc., The University of Toronto, 1969 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in The Faculty of Graduate and Postdoctoral Studies (Interdisciplinary Studies) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) September 2019 © Adrian Cyrus Byram, 2019 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: A proposed paradigm shift for surrogate decision-making in the ICU submitted by Adrian Cyrus Byram in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Interdisciplinary Studies Examining Committee: Judy Illes, Neurology Supervisor Patricia A. Rodney, Nursing Supervisory Committee Member Patrick McDonald, Neurosurgery Supervisory Committee Member Sally Thorne, Nursing University Examiner Stirling Bryan, Medicine University Examiner iii Abstract Each year four million adults in North America require a surrogate to make decisions for them after being admitted to an intensive care unit (ICU). These decisions frequently involve the limitation of life-sustaining treatments. The current paradigm for making these decisions requires surrogates to rely first on any advance directives from the patient, then on the surrogate’s substituted judgment, and finally on best interests as judged by a reasonable person. Since this paradigm emerged 40 years ago, hundreds of research studies have revealed conceptual and operational deficiencies with it and have documented the harms it may cause to patients, surrogates, and medical professionals. The accumulated weight of these studies motivates the central research question of my dissertation: What shifts to the current paradigm for surrogate decision-making might alleviate its clinical and ethical defic…
has type: Thesis/Dissertation
date issued: 2019-11
is shown at: 10.14288/1.0380901
language: eng
degree discipline: Interdisciplinary Studies
provider: Vancouver : University of British Columbia Library
publisher: University of British Columbia
rights: Attribution-NonCommercial-NoDerivatives 4.0 International
rights URI: http://creativecommons.org/licenses/by-nc-nd/4.0/
scholar level: Graduate
type: Text
identifier URI: http://hdl.handle.net/2429/71698