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Special Article | May 09, 2011

On Patient Autonomy and Physician Responsibility in End-of-Life Care

J. Andrew Billings, MD; Eric L. Krakauer, MD, PhD

Arch Intern Med. 2011;171(9):849-853. doi:10.1001/archinternmed.2011.180.

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ABSTRACT

ABSTRACT | QUESTIONS COMMONLY HEARD IN THE HOSPITAL | EVOLVING CONCEPTS OF THE PATIENT-PHYSICIAN RELATIONSHIP | PROGRESS AND PERIL IN THE USE OF LIFE-SUSTAINING TECHNOLOGY | END-OF-LIFE DECISION MAKING TODAY | UNDERSTANDING AUTONOMY | RESPECT FOR AUTONOMY VS FORCING INFORMATION OR DECISION MAKING ONTO A PATIENT | SHARED DECISION MAKING AND RESPECT FOR AUTONOMY | THE IMPORTANCE OF VALUES, GOALS, AND BELIEFS IN END-OF-LIFE CARE | FOCUSING ON OUTCOMES RATHER THAN ON TECHNOLOGICAL MEANS | RESPONSIBILITY IN CRITICAL DECISIONS: THE EXAMPLE OF SURROGATE DECISION MAKING | CONCLUSION | AUTHOR INFORMATION | REFERENCES

In current medical practice, excessive or reflexive deference to an unreflective concept of patient autonomy may inadvertently compromise patient autonomy by placing unwanted and unreasonable responsibility for technical medical decisions on patients or their surrogate decision makers rather than on their physicians. Such practices can harm patients by depriving them of the expert, professional advice they both need and deserve to make important decisions about their health care. We describe herein how the patient-physician relationship has evolved in recent decades as more life-sustaining and life-saving treatments, such as cardiopulmonary resuscitation, have become available. We then examine respect for patient autonomy and describe how patient autonomy can be promoted while the physician's responsibility for technical medical decisions is simultaneously affirmed. The patient is the expert on his or her values, goals, and preferences, while the physician is the expert on the medical means for honoring the patient's perspective. We conclude that an intervention, such as cardiopulmonary resuscitation, should not be offered when, based on the patient's own criteria, it promises no physical or psychosocial benefit or would be far more harmful than beneficial.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit^TM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 Credit^TM.

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Billings J, Krakauer EL. On Patient Autonomy and Physician Responsibility in End-of-Life Care. Arch Intern Med. 2011;171(9):849-853. doi:10.1001/archinternmed.2011.180.

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