Potentially inappropriate treatment and end-of-life care
Stem
Mr. Brennan, an 88-year-old man with advanced dementia who lives in a nursing home, has septic shock from ischemic bowel. He is intubated, anuric, and on norepinephrine and vasopressin; lactate is 9 mmol/L. The surgeon, the ICU attending and you agree that laparotomy is very unlikely to return him to anything like his previous life. He has no advance directive. His daughter, his health care power of attorney, is waiting. Your task: discuss the plan with her.
Question
The surgeon said you're the one who'd put him to sleep. I want everything done for my dad. Why is everyone stalling?
Ideal answer
Headline"I can see how much you love him. I'll give you an honest picture, learn what he would want, and recommend a plan we agree on together."
- Acknowledge, then ask (concern, gather information). "I'm Dr. Reyes, the anesthesiologist. What have the doctors told you so far? What was your dad like before he got sick?"
- Prognosis in pictures (clarify options). "His bowel has lost its blood supply and his organs are failing. Best case, he survives surgery and spends weeks on a breathing machine and dialysis, and never returns to how he was. Most likely, he dies in intensive care after surgery despite everything."
- His voice, not yours (determine preferences). "If he could hear this, what would he say? Did he ever talk about machines, or about what mattered most?"
- Recommend, offer the alternative (negotiate). "From what you've told me, I recommend we focus on his comfort and stop what isn't helping. If you need time, we can continue ICU support without surgery and meet again tomorrow."
- Decide and involve (decide). "Whatever we decide, the whole team will know. Palliative care can help us too. What questions do you have?"
Breaking down the answer
- The words matter — "futile" fits only when an intervention cannot reach its physiologic goal; when it has some chance but ethical considerations argue against it, the term is "potentially inappropriate."1 Changes if: it is truly futile; then I do not provide it and explain why.1
- Best case, worst case — a structured narrative of the likely course with and without surgery helps older patients and families reach goal-concordant decisions; families said it set expectations and gave clarity.2 Changes if: she asks for numbers; I give honest ranges, never false precision.
- Substituted judgment — I ask what he would choose, then what serves his interests if his wishes are unknown. The outline scores determining preferences and negotiating differences.3 Changes if: she relays clear wishes he stated; those lead.
- A recommendation is not coercion — a clear recommendation, then a genuine alternative, spares her from deciding alone without pressuring her. Changes if: she still wants surgery; the conflict process begins, not an argument.1
- When agreement fails — expert consultation; written and verbal notice; second opinion; interdisciplinary committee; offer of transfer; extramural appeal; then implement.1 Changes if: there is no time; a temporizing plan, checked facts and colleague consensus come first.1
Follow-up question
Her voice breaks: "If you stop the machines, will he suffer? Or are you just going to give him morphine until he dies?" How do you respond?
Follow-up answer
HeadlineShe fears we will end his life. I explain that comfort medicines are dosed to his symptoms, never to shorten his life.
"He won't be left to struggle. We watch for signs of pain or breathlessness, like grimacing or fast breathing, and give medicine until they settle, only as much as he needs." I explain that if symptoms ever resist everything else, we can lower his awareness in proportion to his distress, with her agreement, and that the intent is relief, not shortening life.4 I invite her to stay, offer the chaplain, and check what she understood.
Pitfalls that cost points
- "There's nothing more we can do." Comfort care is active treatment.
- Offering surgery and comfort care as an equal menu after concluding surgery will not serve him.
- Debating prognosis statistics instead of answering her grief.
Rapid-fire
Q: "Would you do it for your own father?" A: I answer honestly with my reasoning, then hand the decision back: "But this is about what he would want."
Q: The committee sides with the team; she still refuses. A: Offer transfer to a willing provider; if none, tell her of her right to an independent appeal; then withhold and give high-quality palliative care.1
Q: Is palliative sedation euthanasia? A: No. It treats refractory symptoms, its depth matches distress, and its intent is relief without shortening survival.4
Q: How do I prevent these standoffs? A: Early, proactive communication and early ethics or palliative care involvement.1
Numbers to know
| Item | Value |
|---|---|
| Station time | 8 min, 4-min read, warning at 6 min5 |
| ABA ethical principles | 63 |
| Conflict-resolution steps before implementing | 61 |
| Treatment categories | Futile, potentially inappropriate, legally proscribed, legally discretionary1 |
| Best Case/Worst Case: surgeons preferring it at 3 months | 79%2 |
Links
- Ethical issues: DNR, capacity, surrogates, refusal, Ethical principles reference (ASA guidelines), Treatment options and informed consent, Sepsis and septic shock
- ATS/AACN/ACCP/ESICM/SCCM Policy Statement on Potentially Inappropriate Treatments (2015); AAHPM Statement on Palliative Sedation
Sources
- 1.An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units · American Thoracic Society (Am J Respir Crit Care Med 2015;191:1318-1330), 2015 · thoracic.org
- 2."Best Case/Worst Case": Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems · Journal of Pain and Symptom Management (Kruser et al.), 2017 · ebi.ac.ukAbstract via Europe PMC (PMID 28062349).
- 3.APPLIED Examination OSCE Content Outline · ABA · theaba.orgSection A.3 lists life-sustaining medical treatment and potentially inappropriate treatment among ethics topics.
- 4.Statement on Palliative Sedation · American Academy of Hospice and Palliative Medicine, 2014 · aahpm.orgApproved 2002, revised 2006 and 2014; AAHPM notes it has not been updated since 2014.
- 5.What to Expect for Your APPLIED Exam (APPLIED Exam Manual) · ABA, 2026 · theaba.org
Facts on this page were checked against these sources on Oct 22, 2026. Guidelines change; confirm doses against current institutional protocols.