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December 24/31, 2003

Ethics Consultation in the Intensive Care Unit—Reply

Author Affiliations

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;290(24):3191-3192. doi:10.1001/jama.290.24.3191-a

To the Editor: In their randomized trial, Dr Schneiderman and colleagues1 reported that ethics consultation in the intensive care unit (ICU) led to shorter ICU stays and fewer invasive interventions among patients who apparently would not have benefitted from them. The authors also reported that 80% of patients and surrogates expressed satisfaction with the ethics consultation process. As Dr Lo2 pointed out in his Editorial, the authors apparently excluded non–English-speaking surrogates. I am similarly concerned that these results may overstate the degree of satisfaction, because surrogates were identified for interview by the clinicians involved with the case. I am skeptical that this method for identifying surrogates could have resulted in a representative range of experience and opinion. In my experience, clinicians sometimes identify a particular family member as the most receptive or reasonable, even if that individual is not the identified surrogate or the one most familiar with the patient's wishes. In cases where there is no appointed surrogate, the process of families arriving at treatment consensus on behalf of a loved one can be fractious, with some family members ultimately alienated from the health care team and the hospital setting. It seems likely that the views of marginalized family members were underrepresented in this sample.