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A Randomized Controlled Trial

Lawrence J. Schneiderman, MD; Todd Gilmer, PhD; Holly D. Teetzel, MA; Daniel O. Dugan, PhD; Jeffrey Blustein, PhD; Ronald Cranford, MD; Kathleen B. Briggs, MA, LICSW; Glen I. Komatsu, MD; Paula Goodman-Crews, MSW, LCSW; Felicia Cohn, PhD; Ernlé W. D. Young, PhD

JAMA. 2003;290:1166-1172.

Context  Ethics consultations increasingly are being used to resolve conflicts about life-sustaining interventions, but few studies have reported their outcomes.

Objective  To investigate whether ethics consultations in the intensive care setting reduce the use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, as well as the reactions to the consultations of physicians, nurses, and patients/surrogates.

Design  Prospective, multicenter, randomized controlled trial from November 2000 to December 2002.

Setting  Adult intensive care units (ICUs) of 7 US hospitals representing a spectrum of institutional characteristics.

Patients  Five hundred fifty-one patients in whom value-related treatment conflicts arose during the course of treatment.

Interventions  Patients were randomly assigned either to an intervention (ethics consultation offered) (n = 278) or to usual care (n = 273).

Main Outcome Measures  The primary outcomes were ICU days and life-sustaining treatments in those patients who did not survive to hospital discharge. We examined the same measures in those who did survive to discharge and also compared the overall mortality rates of the intervention and usual care groups. We also interviewed physicians and nurses and patients/surrogates about their views of the ethics consultation.

Results  The intervention and usual-care groups showed no difference in mortality. However, ethics consultations were associated with reductions in hospital (-2.95 days, P = .01) and ICU (-1.44 days, P = .03) days and life-sustaining treatments (-1.7 days with ventilation, P = .03) in those patients who ultimately did not survive to discharge. The majority (87%) of physicians, nurses, and patients/surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts.

Conclusion  Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU.

Author Affiliations: Departments of Family and Preventive Medicine and Medicine, University of California, San Diego, La Jolla (Dr Schneiderman); Department of Family and Preventive Medicine, University of California, San Diego (Dr Gilmer and Ms Teetzel); Ethics Department, Swedish Covenant Hospital, Chicago, Ill (Dr Dugan); Department of Epidemiology and Social Medicine, Montefiore Medical Center, New York, NY (Dr Blustein); Department of Neurology (Dr Cranford) and Social Services Department (Ms Briggs), Hennepin County Medical Center, Minneaplis, Minn; Neonatology and Bioethics/Intensive Care Unit, Little Company of Mary Hospital, Torrence, Calif (Dr Komatsu); Bioethics Consultant/Quality Resource Management, Kaiser Permanente San Diego, San Diego, Calif (Ms Goodman-Crews); Department of Medicine, College of Medicine, University of California, Irvine (Dr Cohn); Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, Calif (Dr Young).

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