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A proposed paradigm shift for surrogate decision-making in ICU Byram, Adrian Cyrus

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 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 capturing the critical values underlying each patient’s individual best interests, and an interest-specific/time-limited decision protocol. Future work will be needed to test the validity and effectiveness of these changes individually and as an integrated solution. Ultimately, the changes I propose are designed to enhance the consistency, continuity, and coordination of care for decisionally incapacitated ICU patients and to yield substantial benefits to surrogate decision-makers and medical professionals.

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Attribution-NonCommercial-NoDerivatives 4.0 International

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