This cross-sectional study evaluates US state regulation of clinician decisions about life-sustaining treatment for adults, including justifications and regulatory requirements.
Abstract Rationale: Disparities in unilateral clinician decisions to decline initiating or maintaining life-sustaining treatment (LST) exist. We aimed to determine 1) which US state statutes support unilateral clinician decisions to decline initiating or maintaining LST; 2) what requirements, if any, must be met for these unilateral clinician decisions to occur; and 3) which state statutes address concerns for sociodemographic disparities associated with these decisions. Methods: Between September and October 2024, we used Fastcase, Casetext and official US state government websites to identify statutes for all US states and Washington, DC that addressed clinician decisions to decline to initiate or maintain LST. We defined reason of conscience as explicit mention of conscience, religion, ethics or moral reasons supporting unilateral clinician decision-making. Two reviewers independently analyzed each statute resolving disagreements with consensus adjudication. Results: Almost all (98%, n=50/51) statutes explicitly support unilateral clinician decisions to decline initiating or maintaining at least one form of LST. Reasons supporting these decisions varied across states including medical reasons only (16%), reasons of conscience only (22%), both medical reasons and reasons of conscience (35%), or no medical or conscience reason explicitly provided (25%). Medical reasons supporting unilateral clinician decisions included if LST was “medically ineffective” (24%), “contrary to medical standards” (14%), “medically inappropriate” (10%), or “nonbeneficial” (8%). For states supporting unilateral clinician decisions if LST was medically ineffective, 75% also supported LST to be declined for reason of conscience while 25% did not. When using medical reasons to support unilateral clinician decisions to decline LST, many statutes require that clinicians must first inform patient/surrogate of this decision (37%) and cooperate with transferring the patient to another clinician or institution (75%). Statutes rarely directly required clinicians to obtain a second medical opinion (8%), pursue a medical ethics committee review (6%), or address conflict (2%) in these situations. Although no state statutes explicitly acknowledged the existence of sociodemographic disparities associated with unilateral clinician decisions to initiate or maintain LST, 27% included guidance that addressed decisions to withhold or withdraw LST in specific marginalized groups. Conclusions: While almost all US state statutes allowed clinicians to decline to initiate or maintain LST, the reasons supporting and actions required to pursue these decisions varied. No statute explicitly addressed sociodemographic disparities associated with these decisions, which may perpetuate these disparities across the US.
Addressing Inadequate Documentation of Unilateral Do-Not-Resuscitate Orders
