660	S. Todi and R. Chawla

Step 10: Resolve areas of conflict

When the family may be pursuing unrealistic demands of continuing futile care as deemed by the treating senior physician, or the physician may be seeking to impose his/her wishes on the family in contradictions to their wishes, conflicts may arise. The proposed course of action in these situations may be as follows:

•A second opinion from another physician not hitherto involved in the care of the patient.

•Multiple counseling sessions explicitly informing the family the hopeless prognosis of the patient and the futility of continuing life support.

•If the family is intransigent, then suggest transfer to another treating team willing to continue support.

•With the help of the hospital administration, set up a committee of doctors to counsel the family. The committee may also take the help of a social worker, psychologist, or a religious person identified by the family to help resolve barriers to understanding.

•Seek a judicial review.

Suggested Reading

1.Silveira MJ, Kim SY. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211–8.

Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives.

2.Luce JM, White DB. A history of ethics and law in the intensive care unit. Crit Care Clin. 2009;25(1):221–37.

This article outlines major events in the history of ethics and law in the ICU, covering the evolution of ICUs, ethical principles, informed consent and the law, medical decision making, cardiopulmonary resuscitation, withholding and withdrawing life-sustaining therapy, legal cases involving life support, advance directives, prognostication, and futility and the allocation of medical resources.

3.Curtis JR, Treece PD. Integrating palliative and critical care: evaluation of a quality-improvement intervention. Am J Respir Crit Care Med. 2008;178(3):269–75.

Improving family satisfaction in end-of-life care may require interventions that have more direct contact with family members.

4.Gerstel E, Engelberg RA. Duration of withdrawal of life support in the intensive care unit and association with family satisfaction. Am J Respir Crit Care Med. 2008;178(8):798–804.

Withdrawal of life support is a complex process that depends on patient and family characteristics. Stuttering withdrawal is a frequent phenomenon that seems to be associated with family satisfaction. Extubation should be encouraged before death if possible.

5.Mani RK, Amin PA. Limiting life-prolonging interventions and providing palliative care towards the end-of-life in Indian intensive care units. Indian J Crit Care Med. 2005;9:96–107.

A position statement by Indian Society of Critical care Medicine for end-of-life care practices.