Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Oct 11;22(1):260.
doi: 10.1186/s13054-018-2187-6.

New perspectives on substituted relational autonomy for shared decision-making in critical care

Nicola Grignoli  1   2   3 , Valentina Di Bernardo  4   5   6 , Roberto Malacrida  4
Affiliations

New perspectives on substituted relational autonomy for shared decision-making in critical care

Nicola Grignoli et al. Crit Care. .

Abstract

In critical care when unconscious patients are assisted by machines, humanity is mainly ensured by respect for autonomy, realised through advance directives or, mostly, reconstructed by cooperation with relatives. Whereas patient-centred approaches are widely discussed and fostered, managing communication in complex, especially end-of-life, situations in open intensive care units is still a point of debate and a possible source of conflict and moral distress. In particular, healthcare teams are often sceptical about the growing role of families in shared decision-making and their ability to represent patients' preferences. New perspectives on substituted relational autonomy are needed for overcoming this climate of suspicion and are discussed through recent literature in the field of medical ethics.

Keywords: Critical care; Medical ethics; Psychology; Relatives; Shared decision-making.

PubMed Disclaimer

Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
The substitute relational autonomy model for SDM in critical care. 1 Previous discussion with patients of therapeutic procedures, clinical team-shared opinion. 2 Knowledge of patients’ health-related quality of life, character and will to live (demonstrated resilience), history of illness. 3 Advanced directives, previous opinions, non-verbal communication. Narrowing represents communication links between parties involved in SDM in critical care
Fig. 2
Fig. 2
Moonlight as an illustration of substituted relational autonomy in critical care. Taking the earth as the individual and its satellite the moon as the relative, moonlight can be seen as what can still shed light on a living will during the night of an unconscious state
See this image and copyright information in PMC

References

    1. Brown SM, Beesley SJ, Hopkins RO. Humanizing intensive care: theory, evidence, and possibilities. In: Vincent JL, editor. Annual update in intensive care and emergency medicine 2016. Cham: Springer; 2016. pp. 405–420.
    1. Caplan AL. Why autonomy needs help. J Med Ethics. 2014;40(5):301–302. doi: 10.1136/medethics-2012-100492. - DOI - PubMed
    1. Rodriguez-Osorio CA, Dominguez-Cherit G. Medical decision making: paternalism versus patient-centered (autonomous) care. Curr Opin Crit Care. 2008;14(6):708–713. doi: 10.1097/MCC.0b013e328315a611. - DOI - PubMed
    1. Wendler D. The theory and practice of surrogate decision-making. Hast Cent Rep. 2017;47(1):29–31. doi: 10.1002/hast.671. - DOI - PubMed
    1. Rubin MA. The collaborative autonomy model of medical decision-making. Neurocrit Care. 2014;20(2):311–318. doi: 10.1007/s12028-013-9922-2. - DOI - PubMed

Publication types