The Burden of Decision Making

Decision making in medicine has changed dramatically over the years. Several decades ago, paternalism was the norm; the physician would tell a patient or family what the best course of action was and that was that. Since then, we've swung way over to the patient autonomy side. We present a patient or surrogate decision maker with information about the risks, benefits, and alternatives of a course of action. We give them information about the diagnosis, tests, treatments. We may even expect them to do some research on the Internet. And what they decide becomes the course of action we take.

Sometimes, especially in constrained circumstances, this can become detrimental. In the intensive care unit, in shifting decision making to a family, we are also shifting the attendant burdens to them as well. Although we ask surrogates to make the decision in the patient's shoes with substituted judgment, they are still making weighty determinations and feel that pressure. I see this over and over again. There is a good amount of guilt that accompanies making someone do-not-resuscitate, even if it is the right thing to do and what the patient would have wanted. In writing the previous few blogs, I've encroached upon those situations where care is futile. Here, it is not the right thing to force the family to make a decision. If something is futile, it shouldn't be chosen, and that choice needs to be removed from the family's hands. When I have a patient who is moribund with no hope for recovery, I don't ask the family whether we should perform CPR if the heart stops. That's futile, and I make the decision and carry the burden of a DNR order. Though some say this is removing autonomy from families, I find that it in fact is relieving them of great stress, pressure, and expectation. I've had families express that my making the decision not to offer futile care made them feel so much better in knowing we were doing the right thing for our patients.