Today's podcast is a natural follow up to our podcasts on Slow Codes and Unilateral DNR orders.Today we talk about a new study about how clinicians talk about potentially non-beneficial life-prolonging treatments, published in JAMA Network Open. Do they adhere to society guidelines, which allow as permissible approaches only shared decision-making and following institutional policy. Or do they take alternative approaches, like not offering interventions, not mentioning interventions, or simply stating a plan to limit interventions? Turns out doctors are using these alternative approaches frequently.

Our guests are Jason Batten, Liz Dzeng, and Teva Brender, all clinicians, all of whom have been thinking about and wrestling with the ethical reasoning behind these approaches. We all admit to using these approaches. Are the alternative approaches wicked games (song hint), and our response should be to stop these behaviors, beginning with ourselves? After all, if you ask patients or surrogates, they're likely to say they want all the options and may not universally welcome recommendations. Or, as with slow codes, does the fact that these alternative approaches are in common use suggest that the guidelines should be revised? You listen and decide!

-Alex Smith

Additional links:

Dzeng 2023 JAMA IM: The larger ethnographic study from which data was drawn with data drawn from high- medium- and low-intensity hospitals.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2806959

Brender 2025 JAMA NO: Factors that exacerbate or mitigate moral distress related to potentially non-beneficial treatments.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2835316

Dzeng 2015 JAMA IM: Study illustrating that more senior physicians feel more comfortable not offering or recommending against futile CPR. Relevant quote: "Experienced physicians at all sites generally were comfortable engaging in best interest decision making and, when clinically appropriate, not offering or making explicit recommendations against offering resuscitation."
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2212265

Weiss Goitiandia AJOB 2025: Reasons why some clinicians would hesitate to go to the ethics committee / futility process for these discussions:
https://www.tandfonline.com/doi/10.1080/15265161.2025.2457734?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Axelrod AJOB 2025: Discusses some of the systemic consequences of using physiologic futility as a standard and how it might contribute to a healthcare system that imposes aggressive treatments on vulnerable patients.
https://www.tandfonline.com/doi/full/10.1080/15265161.2025.2530715#d1e152