Log in | Register

Competing and conflicting interests in the care of critically ill patients

Alison E. Turnbull| Sarina K. Sahetya| E. Lee Daugherty Biddison| Christiane S. Hartog| Gordon D. Rubenfeld| Dominique D. Benoit| Bertrand Guidet| Rik T. Gerritsen| Mark R. Tonelli| J. Randall Curtis
Review
Volume 44, Issue 10 / October , 2018

Pages 1628 - 1637

Abstract

Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician’s sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient’s best interest and discusses steps that could help minimize the impact of these factors on patient care.

Keywords

References

  1. Gauchat G (2012) Politicization of science in the public sphere: a study of public trust in the United States, 1974 to 2010. Am Soc Rev 77:167–187. https://doi.org/10.1177/0003122412438225
    • View reference on publisher's website
  2. Malone C (2016) Americans don’t trust their institutions anymore. In: FiveThirtyEight. https://fivethirtyeight.com/features/americans-dont-trust-their-institutions-anymore/. Accessed 18 Apr 2018
  3. Funk C (2017) Mixed messages about public trust in science. In: Pew. Res. Cent. Int. Sci. Tech. http://www.pewinternet.org/2017/12/08/mixed-messages-about-public-trust-in-science/. Accessed 18 Apr 2018
  4. Cook K (2003) Trust in Society. Russell Sage Foundation, New York
  5. Hardin R (2004) Trust and Trustworthiness. Russell Sage Foundation, New York
  6. AMA Council on Ethical and Judicial Affairs (2016) AMA code of medical ethics. American Medical Association, Chicago
  7. Gamble VN (1997) Under the shadow of Tuskegee: african Americans and health care. Am J Public Health 87:1773–1778
    • View reference on publisher's website
    • View reference on PubMed
  8. Jones DS (2002) The health care experiments at many farms: the Navajo, Tuberculosis, and the Limits of modern medicine, 1952–1962. Bull Hist Med 76:749–790. https://doi.org/10.1353/bhm.2002.0186
    • View reference on publisher's website
    • View reference on PubMed
  9. Stern AM (2005) Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health 95:1128–1138. https://doi.org/10.2105/AJPH.2004.041608
    • View reference on publisher's website
    • View reference on PubMed
  10. Stell LK (2004) Two cheers for physicians’ conflicts of interest. Mt Sinai J Med N Y 71:236–242
  11. Schünemann HJ, Osborne M, Moss J et al (2009) An official American Thoracic Society Policy statement: managing conflict of interest in professional societies. Am J Respir Crit Care Med 180:564–580. https://doi.org/10.1164/rccm.200901-0126ST
    • View reference on publisher's website
    • View reference on PubMed
  12. McCoy MS, Emanuel EJ (2017) Why there are no “potential” conflicts of interest. JAMA 317:1721–1722. https://doi.org/10.1001/jama.2017.2308
    • View reference on publisher's website
  13. Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice (2009) Conflict of Interest in Medical Research, Education, and Practice. National Academies Press (US), Washington (DC)
  14. Diener E, Scollon CN, Lucas RE (2009) The evolving concept of subjective well-being: The multifaceted nature of happiness. In: Diener Ed (ed) Assessing well-being: The collected works of Ed Diener. Springer, New York, 67–100
  15. McClellan M, McKethan AN, Lewis JL et al (2010) A national strategy to put accountable care into practice. Health Aff Proj Hope 29:982–990. https://doi.org/10.1377/hlthaff.2010.0194
    • View reference on publisher's website
  16. Pimperl A, Schulte T, Mühlbacher A et al (2017) Evaluating the impact of an accountable care organization on population health: the quasi-experimental design of the German Gesundes Kinzigtal. Popul Health Manag 20:239–248. https://doi.org/10.1089/pop.2016.0036
    • View reference on publisher's website
    • View reference on PubMed
  17. Tonelli MR (2007) Conflict of interest in clinical practice. Chest 132:664–670. https://doi.org/10.1378/chest.07-0315
    • View reference on publisher's website
    • View reference on PubMed
  18. Evans S, Darvall J, Gorelik A, Bellomo R (2018) Influence of ward round order on critically ill patient outcomes. J Crit Care 45:110–113. https://doi.org/10.1016/j.jcrc.2018.02.003
    • View reference on publisher's website
    • View reference on PubMed
  19. Stepanikova I (2012) Racial-ethnic biases, time pressure, and medical decisions. J Health Soc Behav 53:329–343. https://doi.org/10.1177/0022146512445807
    • View reference on publisher's website
    • View reference on PubMed
  20. FitzGerald C, Hurst S (2017) Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. https://doi.org/10.1186/s12910-017-0179-8
    • View reference on publisher's website
    • View reference on PubMed
  21. Evans TW, Nava S, Mata GV et al (2011) Critical care rationing: international comparisons. Chest 140:1618–1624. https://doi.org/10.1378/chest.11-0957
    • View reference on publisher's website
    • View reference on PubMed
  22. Mielke J, Martin DK, Singer PA (2003) Priority setting in a hospital critical care unit: qualitative case study. Crit Care Med 31:2764–2768. https://doi.org/10.1097/01.CCM.0000098440.74735.DE
    • View reference on publisher's website
    • View reference on PubMed
  23. Cooper AB, Joglekar AS, Gibson J et al (2005) Communication of bed allocation decisions in a critical care unit and accountability for reasonableness. BMC Health Serv Res 5:67. https://doi.org/10.1186/1472-6963-5-67
    • View reference on publisher's website
    • View reference on PubMed
  24. Pope T (2017) Legal briefing: new penalties for disregarding advance directives and do-not-resuscitate orders. J Clin Ethics Spring 28:74–81
  25. Abadir PM, Finucane TE, McNabney MK (2011) When doctors and daughters disagree: twenty-two days and two blinks of an eye. J Am Geriatr Soc 59:2337–2340. https://doi.org/10.1111/j.1532-5415.2011.03700.x
    • View reference on publisher's website
    • View reference on PubMed
  26. Reilly BM (2014) Don’t learn on me—are teaching Hospitals Patient-Centered? N Engl J Med 371:293–295. https://doi.org/10.1056/NEJMp1405709
    • View reference on publisher's website
    • View reference on PubMed
  27. Laugesen MJ (2014) The resource-based relative value scale and physician reimbursement policy. Chest 146:1413–1419. https://doi.org/10.1378/chest.13-2367
    • View reference on publisher's website
    • View reference on PubMed
  28. Holt E (2015) Slovak bribery case sparks wider debate in eastern Europe. The Lancet 385:2242. https://doi.org/10.1016/S0140-6736(15)61051-0
    • View reference on publisher's website
  29. Kakuk P, Domján A (2013) Healthcare financing and conflict of interests in hungary: the system of irregular payments and its challenges to the integrity of healthcare ethics. Camb Q Healthc Ethics 22:263–270. https://doi.org/10.1017/S0963180113000078
    • View reference on publisher's website
    • View reference on PubMed
  30. Manea T (2015) Medical Bribery and the ethics of trust: the Romanian case. J Med Philos 40:26–43
    • View reference on publisher's website
    • View reference on PubMed
  31. Burashnikova IS, Ziganshin AU, Ziganshina LE (2008) Attitudes to pharmaceutical promotion techniques among healthcare professionals in the Republic of Tatarstan, Russia. Int J Risk Saf Med 20:57–71. https://doi.org/10.3233/JRS-2008-0425
    • View reference on publisher's website
  32. Jofre S (2014) GSK faces accusations of bribing doctors in Poland. BMJ 348:g2768. https://doi.org/10.1136/bmj.g2768
    • View reference on publisher's website
    • View reference on PubMed
  33. Jena AB, Seabury S, Lakdawalla D, Chandra A (2011) Malpractice risk according to physician specialty. N Engl J Med 365:629–636. https://doi.org/10.1056/NEJMsa1012370
    • View reference on publisher's website
    • View reference on PubMed
  34. Mello MM, Chandra A, Gawande AA, Studdert DM (2010) National costs of the medical liability system. Health Aff Proj Hope 29:1569–1577. https://doi.org/10.1377/hlthaff.2009.0807
    • View reference on publisher's website
  35. Rothberg MB, Class J, Bishop TF et al (2014) The cost of defensive medicine on 3 Hospital Medicine Services. JAMA Intern Med 174:1867–1868. https://doi.org/10.1001/jamainternmed.2014.4649
    • View reference on publisher's website
    • View reference on PubMed
  36. Burns KEA, Zubrinich C, Tan W et al (2013) Research recruitment practices and critically Ill patients. Am J Respir Crit Care Med 187:1212–1218. https://doi.org/10.1164/rccm.201208-1537OC
    • View reference on publisher's website
    • View reference on PubMed
  37. Schandelmaier S, von Elm E, You JJ et al (2016) Premature discontinuation of randomized trials in critical and emergency care: a retrospective cohort study. Crit Care Med 44:130–137. https://doi.org/10.1097/CCM.0000000000001369
    • View reference on publisher's website
    • View reference on PubMed
  38. Silverman H, Hull SC, Sugarman J (2001) Variability among institutional review boards’ decisions within the context of a multicenter trial. Crit Care Med 29:235–241
    • View reference on publisher's website
    • View reference on PubMed
  39. Khan MA, Barratt MS, Krugman SD et al (2014) Variability of the institutional review board process within a national research network. Clin Pediatr (Phila) 53:556–560. https://doi.org/10.1177/0009922814527504
    • View reference on publisher's website
  40. Mehter HM, Wiener RS, Walkey AJ (2014) “Do not resuscitate” decisions in acute respiratory distress syndrome: a secondary analysis of clinical trial data. Ann Am Thorac Soc 11:1592–1596. https://doi.org/10.1513/AnnalsATS.201406-244BC
    • View reference on publisher's website
    • View reference on PubMed
  41. Darmon M, Ducos G, Coquet I et al (2016) Formal academic training on ethics may address junior physicians’ needs. Chest 150:180–187. https://doi.org/10.1016/j.chest.2016.02.651
    • View reference on publisher's website
    • View reference on PubMed
  42. Rushton CH, Batcheller J, Schroeder K, Donohue P (2015) Burnout and resilience among nurses practicing in high-intensity settings. Am J Crit Care 24:412–420. https://doi.org/10.4037/ajcc2015291
    • View reference on publisher's website
    • View reference on PubMed
  43. Marik PE, Khangoora V, Rivera R et al (2017) Hydrocortisone, vitamin C, and Thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study. Chest 151:1229–1238. https://doi.org/10.1016/j.chest.2016.11.036
    • View reference on publisher's website
    • View reference on PubMed
  44. Simpson E A Norfolk doctor found a treatment for sepsis. Now he’s trying to get the ICU world to listen. In: Virginian-Pilot. http://pilotonline.com/news/local/health/article_7a3063e5-24cf-56c1-b25c-142731604196.html. Accessed 23 Apr 2018
  45. Did An IV Cocktail Of Vitamins And Drugs Save This Lumberjack From Sepsis? In: NPR.org. https://www.npr.org/sections/health-shots/2018/02/21/583845485/did-an-iv-cocktail-of-vitamins-and-drugs-save-this-lumberjack-from-sepsis. Accessed 23 Apr 2018
  46. Smith R, Blazeby J (2018) Why religious belief should be declared as a competing interest. BMJ 361:k1456. https://doi.org/10.1136/bmj.k1456
    • View reference on publisher's website
    • View reference on PubMed
  47. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J (2016) Attitudes and practices of euthanasia and physician-assisted suicide in the united states, canada, and europe. JAMA 316:79–90. https://doi.org/10.1001/jama.2016.8499
    • View reference on publisher's website
    • View reference on PubMed
  48. Pope T (2018) Legal history of medical aid in dying: physician assisted death in US courts and legislatures. NML Rev 48:267
  49. Fiala C, Gemzell Danielsson K, Heikinheimo O et al (2016) Yes we can! Successful examples of disallowing “conscientious objection” in reproductive health care. Eur J Contracept Reprod Health Care Off J Eur Soc Contracept 21:201–206. https://doi.org/10.3109/13625187.2016.1138458
    • View reference on publisher's website
  50. Lewis-Newby M, Wicclair M, Pope T et al (2015) An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med 191:219–227. https://doi.org/10.1164/rccm.201410-1916ST
    • View reference on publisher's website
    • View reference on PubMed
  51. Stahl RY, Emanuel EJ (2017) Physicians, not conscripts—conscientious objection in health care. N Engl J Med 376:1380–1385. https://doi.org/10.1056/NEJMsb1612472
    • View reference on publisher's website
    • View reference on PubMed
  52. Wehkamp K-H, Naegler H (2017) The commercialization of patient-related decision making in hospitals. Dtsch Arzteblatt Int 114:797–804. https://doi.org/10.3238/arztebl.2017.0797
    • View reference on publisher's website
  53. Blum JM, Lynch WR, Coopersmith CM (2015) Clinical and billing review of extracorporeal membrane oxygenation. Chest 147:1697–1703. https://doi.org/10.1378/chest.14-2954
    • View reference on publisher's website
    • View reference on PubMed
  54. Li X, Scales DC, Kavanagh BP (2018) Unproven and expensive before proven and cheap: extracorporeal membrane oxygenation versus prone position in acute respiratory distress syndrome. Am J Respir Crit Care Med 197:991–993. https://doi.org/10.1164/rccm.201711-2216CP
    • View reference on publisher's website
    • View reference on PubMed
  55. Schwarze ML, Brasel KJ, Mosenthal AC (2014) Beyond 30-day mortality: aligning surgical quality with outcomes that patients value. JAMA Surg 149:631–632. https://doi.org/10.1001/jamasurg.2013.5143
    • View reference on publisher's website
    • View reference on PubMed
  56. Walkey AJ, Barnato AE, Wiener RS, Nallamothu BK (2017) Accounting for patient preferences regarding life-sustaining treatment in evaluations of medical effectiveness and quality. Am J Respir Crit Care Med 196:958–963. https://doi.org/10.1164/rccm.201701-0165CP
    • View reference on publisher's website
    • View reference on PubMed
  57. Nash IS (2015) Why physicians hate “patient satisfaction” but shouldn’t. Ann Intern Med 163:792. https://doi.org/10.7326/M15-1087
    • View reference on publisher's website
    • View reference on PubMed
  58. Fenton JJ, Jerant AF, Bertakis KD, Franks P (2012) The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 172:405–411. https://doi.org/10.1001/archinternmed.2011.1662
    • View reference on publisher's website
    • View reference on PubMed
  59. Zgierska A, Miller M, Rabago D (2012) Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA 307:1377–1378. https://doi.org/10.1001/jama.2012.419
    • View reference on publisher's website
    • View reference on PubMed
  60. Johnston C (2013) Patient satisfaction and its discontents. JAMA Intern Med 173:2025–2026. https://doi.org/10.1001/jamainternmed.2013.11356
    • View reference on publisher's website
    • View reference on PubMed
  61. Blumenthal-Barby JS, Krieger H (2015) Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy. Med Decis Making 35:539–557. https://doi.org/10.1177/0272989X14547740
    • View reference on publisher's website
    • View reference on PubMed
  62. Saposnik G, Redelmeier D, Ruff CC, Tobler PN (2016) Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak 16:138. https://doi.org/10.1186/s12911-016-0377-1
    • View reference on publisher's website
    • View reference on PubMed
  63. Hartog CS, Skupin H, Natanson C et al (2012) Systematic analysis of hydroxyethyl starch (HES) reviews: proliferation of low-quality reviews overwhelms the results of well-performed meta-analyses. Intensive Care Med 38:1258–1271. https://doi.org/10.1007/s00134-012-2614-0
  64. Wood SF, Podrasky J, McMonagle MA et al (2017) Influence of pharmaceutical marketing on Medicare prescriptions in the District of Columbia. PLoS One 12:e0186060. https://doi.org/10.1371/journal.pone.0186060
    • View reference on publisher's website
    • View reference on PubMed
  65. Rodwin MA (1989) Physicians’ conflicts of interest. N Engl J Med 321:1405–1408. https://doi.org/10.1056/NEJM198911163212010
    • View reference on publisher's website
    • View reference on PubMed
  66. Dana J, Loewenstein G (2003) A social science perspective on gifts to physicians from industry. JAMA 290:252–255. https://doi.org/10.1001/jama.290.2.252
    • View reference on publisher's website
    • View reference on PubMed
  67. Wegwarth O, Gigerenzer G (2018) The barrier to informed choice in cancer screening: statistical illiteracy in physicians and patients. Recent Results Cancer Res Fortschritte Krebsforsch Progres Dans Rech Sur Cancer 210:207–221. https://doi.org/10.1007/978-3-319-64310-6_13
    • View reference on publisher's website
  68. Netzer G, Sullivan DR (2014) Recognizing, naming, and measuring a family intensive care unit syndrome. Ann Am Thorac Soc 11:435–441. https://doi.org/10.1513/AnnalsATS.201309-308OT
    • View reference on publisher's website
    • View reference on PubMed
  69. Cain DM, Loewenstein G, Moore DA (2005) The dirt on coming clean: perverse effects of disclosing conflicts of interest. J Leg Stud 34:1–25. https://doi.org/10.1086/426699
    • View reference on publisher's website
  70. Loewenstein G, Sah S, Cain DM (2012) The unintended consequences of conflict of interest disclosure. JAMA 307:669–670. https://doi.org/10.1001/jama.2012.154
    • View reference on publisher's website
    • View reference on PubMed
  71. Lo B (2012) The future of conflicts of interest: a call for professional standards. J Law Med Ethics 40:441–451. https://doi.org/10.1111/j.1748-720X.2012.00677.x
    • View reference on publisher's website
    • View reference on PubMed
  72. Courtwright AM, Brackett S, Cadge W et al (2015) Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial. J Crit Care 30:173–177. https://doi.org/10.1016/j.jcrc.2014.10.003
    • View reference on publisher's website
    • View reference on PubMed
  73. Olson LL (1998) Hospital nurses’ perceptions of the ethical climate of their work setting. Image–. J Nurs Scholarsh 30:345–349
    • View reference on publisher's website
  74. Van den Bulcke B, Piers R, Jensen HI et al (2018) Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool. BMJ Qual Saf. https://doi.org/10.1136/bmjqs-2017-007390
    • View reference on publisher's website
    • View reference on PubMed
  75. Benoit DD, Jensen HI, Malmgren J et al (2018) Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA. Intensive Care Med. https://doi.org/10.1007/s00134-018-5231-8
  76. Dzeng E, Colaianni A, Roland M et al (2015) Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life. JAMA Intern Med 175:812–819. https://doi.org/10.1001/jamainternmed.2015.0295
    • View reference on publisher's website
    • View reference on PubMed
  77. Dzeng E, Dohan D, Curtis JR et al (2018) Homing in on the social: system-level influences on overly aggressive treatments at the end of life. J Pain Symptom Manag 55(282–289):e1. https://doi.org/10.1016/j.jpainsymman.2017.08.019
    • View reference on publisher's website
  78. Barnato AE, Tate JA, Rodriguez KL et al (2012) Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med 38:1886–1896. https://doi.org/10.1007/s00134-012-2661-6
  79. Kelley AS, Bollens-Lund E, Covinsky KE et al (2017) Prospective identification of patients at risk for unwarranted variation in treatment. J Palliat Med 21:44–54. https://doi.org/10.1089/jpm.2017.0063
    • View reference on publisher's website
    • View reference on PubMed
  80. Fields ProPublica R (2010) God help you. You’re on dialysis. The Atlantic, Washington DC, USA
  81. Rivière P (2003) Case notes on corruption. Monde Dipl, Paris, France
  82. Creswell J, Abelson R, Sanger-Katz M (2017) The company behind many surprise emergency room bills. N. Y. Times, New York, NY, USA
  83. Ornstein C, Hixenbaugh M (2018) At St. Luke’s in Houston, Patients Suffer as a Renowned Heart Transplant Program Loses Its Luster. In: ProPublica. https://www.propublica.org/article/baylor-st-lukes-medical-center-heart-transplants-houston-texas-patients-suffer. Accessed 16 May 2018

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement