{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T03:47:01Z","timestamp":1792554421563,"version":"4.5.0"},"reference-count":50,"publisher":"American Medical Association (AMA)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Professional society policy statements recommend that clinicians limit (ie, withhold or withdraw) potentially nonbeneficial life-prolonging interventions by (1) achieving a shared decision with patients or surrogates or (2) initiating an institutional process to address disagreement with patients or surrogates. However, in the context of a health care system with a default tendency toward life prolongation, it is unclear whether clinicians rely entirely on these recommended approaches or resort to alternate approaches.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To characterize the range of decision-making approaches clinicians report using to limit potentially nonbeneficial life-prolonging interventions.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This qualitative study was conducted at 3 tertiary academic medical centers in Washington and California. Clinicians were sampled from emergency department, medical ward, medical intensive care unit, geriatrics, and palliative care services between February 2018 and June 2022 for in-depth, semistructured interviews. Results were analyzed between August 2023 and May 2025.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n After qualitatively analyzing interviews to identify decision-making approaches, we developed a framework of approaches that categorized each as a recommended or alternate approach.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n We conducted 101 interviews (53 attending physicians [52%], 16 trainee physicians [16%], 6 advanced practice clinicians [6%], 21 nurses [21%], 3 chaplains [3%], and 2 social workers [2%]; 59 women [58%], 42 men [42%]; mean age, 42 years [range, 27-74 years]; mean years of experience, 14 [range, 1-52]). We identified 6 decision-making approaches: (1) providing an informed choice regarding interventions, (2) making a recommendation to limit interventions, (3) stating a plan to limit interventions, (4) explicitly not offering interventions, and (5) not mentioning interventions. In rare cases of intractable conflict, clinicians reported using an option of last resort: (6) invoking an institutional process to limit interventions. Respondents reported challenges with limiting interventions via the recommended approaches of shared decision-making (approaches 1-3) and institutional processes (approach 6), which sometimes discouraged the use of these approaches. While respondents recounted successfully using alternate approaches (approaches 3-5), they described interclinician and interhospital practice variation, as well as ethical and practical uncertainties.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this qualitative study, clinicians reported substantial challenges using recommended approaches to limit potentially nonbeneficial life-prolonging interventions. Some clinicians reported using alternate approaches that are not supported in professional society policy statements.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.60260","type":"journal-article","created":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T16:30:43Z","timestamp":1771605043000},"page":"e2560260","source":"Crossref","is-referenced-by-count":3,"title":["Decision-Making Approaches Used to Limit Potentially Nonbeneficial Life-Prolonging Interventions"],"prefix":"10.1001","volume":"9","author":[{"given":"Jason N.","family":"Batten","sequence":"first","affiliation":[{"name":"Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sofia","family":"Weiss Goitiandia","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia K.","family":"Axelrod","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helen O.","family":"Chernicoff","sequence":"additional","affiliation":[{"name":"Department of Palliative Medicine, Swedish Cherry Hill, Seattle, Washington"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ariadne A.","family":"Nichol","sequence":"additional","affiliation":[{"name":"School of Medicine, University of California, San Diego, San Diego"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorraine M.","family":"Pereira","sequence":"additional","affiliation":[{"name":"Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacob A.","family":"Blythe","sequence":"additional","affiliation":[{"name":"Harvard Medical School, Boston, Massachusetts"},{"name":"Department of Radiology, Massachusetts General Hospital, Boston"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacqueline M.","family":"Kruser","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Allergy, Pulmonary, and Critical Care; University of Wisconsin-Madison, Madison"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth W.","family":"Dzeng","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco"},{"name":"Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco"},{"name":"Cicely Saunders Institute, King\u2019s College London, London, England"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,2,20]]},"reference":[{"issue":"2","key":"zoi251612r1","doi-asserted-by":"publisher","first-page":"282","DOI":"10.1016\/j.jpainsymman.2017.08.019","article-title":"Homing in on the social: system-level influences on overly aggressive treatments at the end of life.","volume":"55","author":"Dzeng","year":"2018","journal-title":"J Pain Symptom Manage"},{"issue":"8","key":"zoi251612r2","doi-asserted-by":"publisher","first-page":"839","DOI":"10.1001\/jamainternmed.2023.2450","article-title":"Hospital culture and intensity of end-of-life care at 3 academic medical centers.","volume":"183","author":"Dzeng","year":"2023","journal-title":"JAMA Intern Med"},{"issue":"3","key":"zoi251612r3","doi-asserted-by":"publisher","first-page":"426","DOI":"10.1513\/AnnalsATS.201611-931OI","article-title":"Clinical momentum in the intensive care unit: a latent contributor to unwanted care.","volume":"14","author":"Kruser","year":"2017","journal-title":"Ann Am Thorac Soc"},{"issue":"6","key":"zoi251612r4","doi-asserted-by":"publisher","first-page":"784","DOI":"10.1097\/CCM.0000000000003711","article-title":"Patient and family engagement during treatment decisions in an ICU: a discourse analysis of the electronic health record.","volume":"47","author":"Kruser","year":"2019","journal-title":"Crit Care Med"},{"issue":"7","key":"zoi251612r5","doi-asserted-by":"publisher","first-page":"613","DOI":"10.1016\/S2213-2600(19)30170-5","article-title":"Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals.","volume":"7","author":"Khandelwal","year":"2019","journal-title":"Lancet Respir Med"},{"issue":"16","key":"zoi251612r6","doi-asserted-by":"publisher","first-page":"1451","DOI":"10.1056\/NEJMp2314068","article-title":"Beyond code status.","volume":"390","author":"Aronson","year":"2024","journal-title":"N Engl J Med"},{"issue":"4","key":"zoi251612r9","doi-asserted-by":"publisher","first-page":"456","DOI":"10.1093\/intqhc\/mzw060","article-title":"Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem.","volume":"28","author":"Cardona-Morrell","year":"2016","journal-title":"Int J Qual Health Care"},{"issue":"14","key":"zoi251612r10","doi-asserted-by":"publisher","first-page":"1665","DOI":"10.1001\/jama.300.14.1665","article-title":"Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.","volume":"300","author":"Wright","year":"2008","journal-title":"JAMA"},{"issue":"1","key":"zoi251612r11","doi-asserted-by":"publisher","first-page":"107","DOI":"10.1007\/s00134-019-05781-0","article-title":"Financial stress after critical illness: an unintended consequence of high-intensity care.","volume":"46","author":"Khandelwal","year":"2020","journal-title":"Intensive Care Med"},{"issue":"20","key":"zoi251612r12","doi-asserted-by":"publisher","first-page":"1887","DOI":"10.1001\/jamainternmed.2013.10261","article-title":"The frequency and cost of treatment perceived to be futile in critical care.","volume":"173","author":"Huynh","year":"2013","journal-title":"JAMA Intern Med"},{"issue":"9","key":"zoi251612r13","doi-asserted-by":"publisher","first-page":"1977","DOI":"10.1097\/CCM.0000000000000402","article-title":"The opportunity cost of futile treatment in the ICU.","volume":"42","author":"Huynh","year":"2014","journal-title":"Crit Care Med"},{"issue":"1","key":"zoi251612r14","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1016\/j.chest.2016.02.649","article-title":"An official critical care societies collaborative statement-burnout syndrome in critical care health-care professionals: a call for action.","volume":"150","author":"Moss","year":"2016","journal-title":"Chest"},{"issue":"6","key":"zoi251612r15","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2025.16089","article-title":"Clinicians\u2019 perceptions about institutional factors in moral distress related to potentially nonbeneficial treatments.","volume":"8","author":"Brender","year":"2025","journal-title":"JAMA Netw Open"},{"issue":"7","key":"zoi251612r16","doi-asserted-by":"publisher","first-page":"558","DOI":"10.1016\/S2213-2600(19)30169-9","article-title":"Why is it so hard to stop doing things that are unwanted, non-beneficial, or unsustainable?","volume":"7","author":"Kyeremanteng","year":"2019","journal-title":"Lancet Respir Med"},{"issue":"1","key":"zoi251612r17","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1186\/s13054-015-0777-0","article-title":"Perceptions of the appropriateness of care in California adult intensive care units.","volume":"19","author":"Anstey","year":"2015","journal-title":"Crit Care"},{"key":"zoi251612r18","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1016\/j.jcrc.2020.08.028","article-title":"Change in inappropriate critical care over time.","volume":"60","author":"Neville","year":"2020","journal-title":"J Crit Care"},{"issue":"1","key":"zoi251612r19","doi-asserted-by":"publisher","first-page":"188","DOI":"10.1097\/CCM.0000000000001396","article-title":"Shared decision making in ICUs: an American College of Critical Care Medicine and American Thoracic Society policy statement.","volume":"44","author":"Kon","year":"2016","journal-title":"Crit Care Med"},{"issue":"11","key":"zoi251612r20","doi-asserted-by":"publisher","first-page":"1318","DOI":"10.1164\/rccm.201505-0924ST","article-title":"An official ATS\/AACN\/ACCP\/ESICM\/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units.","volume":"191","author":"Bosslet","year":"2015","journal-title":"Am J Respir Crit Care Med"},{"issue":"9","key":"zoi251612r21","doi-asserted-by":"publisher","first-page":"1769","DOI":"10.1097\/CCM.0000000000001965","article-title":"Defining futile and potentially inappropriate interventions: a policy statement from the Society of Critical Care Medicine Ethics Committee.","volume":"44","author":"Kon","year":"2016","journal-title":"Crit Care Med"},{"issue":"1","key":"zoi251612r22","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1086\/JCE2021321048","article-title":"Perspectives on the effectiveness of a medical futility policy.","volume":"32","author":"Kaps","year":"2021","journal-title":"J Clin Ethics"},{"issue":"1","key":"zoi251612r23","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1001\/jamasurg.2021.4425","article-title":"Surgical overtreatment and shared decision-making-the limits of choice.","volume":"157","author":"Clapp","year":"2022","journal-title":"JAMA Surg"},{"issue":"1","key":"zoi251612r24","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1002\/hast.664","article-title":"After the DNR: surrogates who persist in requesting cardiopulmonary resuscitation.","volume":"47","author":"Robinson","year":"2017","journal-title":"Hastings Cent Rep"},{"issue":"3","key":"zoi251612r25","doi-asserted-by":"publisher","first-page":"255","DOI":"10.1001\/jama.2015.18681","article-title":"Toward better ICU use at the end of life.","volume":"315","author":"Angus","year":"2016","journal-title":"JAMA"},{"issue":"3","key":"zoi251612r26","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1007\/s11673-023-10270-7","article-title":"Declining to provide or continue requested life-sustaining treatment: experience with a hospital resolving conflict policy.","volume":"20","author":"Rubin","year":"2023","journal-title":"J Bioeth Inq"},{"issue":"2","key":"zoi251612r27","doi-asserted-by":"publisher","first-page":"151","DOI":"10.1001\/jama.2011.1990","article-title":"The courts, futility, and the ends of medicine.","volume":"307","author":"White","year":"2012","journal-title":"JAMA"},{"issue":"5","key":"zoi251612r28","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1002\/hast.356","article-title":"Surgeons, intensivists, and discretion to refuse requested treatments.","volume":"44","author":"Wicclair","year":"2014","journal-title":"Hastings Cent Rep"},{"issue":"1","key":"zoi251612r29","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/15265161.2016.1128748","article-title":"Professional judgment and justice: equal respect for the professional judgment of critical-care physicians.","volume":"16","author":"Magnus","year":"2016","journal-title":"Am J Bioeth"},{"issue":"3","key":"zoi251612r30","doi-asserted-by":"publisher","first-page":"305","DOI":"10.1001\/jamainternmed.2018.6197","article-title":"Care practices for patients with advanced kidney disease who forgo maintenance dialysis.","volume":"179","author":"Wong","year":"2019","journal-title":"JAMA Intern Med"},{"issue":"6","key":"zoi251612r31","doi-asserted-by":"publisher","first-page":"851","DOI":"10.1001\/jamainternmed.2019.1227","article-title":"\u201cNot shared\u201d need not mean \u201cnot patient centered\u201d: deciding that a patient is not a candidate.","volume":"179","author":"Blythe","year":"2019","journal-title":"JAMA Intern Med"},{"issue":"1","key":"zoi251612r32","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1007\/s43999-022-00006-2","article-title":"The Dartmouth Atlas of Health Care\u2014bringing health care analyses to health systems, policymakers, and the public.","volume":"1","author":"Bronner","year":"2022","journal-title":"Res Health Serv Reg"},{"issue":"03","key":"zoi251612r33","first-page":"3","article-title":"The constant comparative method of qualitative analysis.","volume":"7","author":"Glaser","year":"2008","journal-title":"Grounded Theory Rev"},{"issue":"1","key":"zoi251612r34","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1177\/1049732312466295","article-title":"Desperately seeking dissonance: identifying the disconfirming case in qualitative evidence synthesis.","volume":"23","author":"Booth","year":"2013","journal-title":"Qual Health Res"},{"issue":"10","key":"zoi251612r36","doi-asserted-by":"publisher","first-page":"53","DOI":"10.1097\/01.NAJ.0000525875.82101.b7","article-title":"Workarounds are routinely used by nurses\u2014but are they ethical?","volume":"117","author":"Berlinger","year":"2017","journal-title":"Am J Nurs"},{"issue":"3","key":"zoi251612r37","doi-asserted-by":"publisher","first-page":"243","DOI":"10.1089\/jpm.2012.0331","article-title":"\u201cIt hurts to know... and it helps\u201d: exploring how surrogates in the ICU cope with prognostic information.","volume":"16","author":"Schenker","year":"2013","journal-title":"J Palliat Med"},{"issue":"12","key":"zoi251612r38","doi-asserted-by":"publisher","first-page":"1657","DOI":"10.1007\/s11606-012-2129-y","article-title":"I don\u2019t want to be the one saying \u2018we should just let him die\u2019: intrapersonal tensions experienced by surrogate decision makers in the ICU.","volume":"27","author":"Schenker","year":"2012","journal-title":"J Gen Intern Med"},{"issue":"6","key":"zoi251612r39","doi-asserted-by":"publisher","first-page":"1070","DOI":"10.1016\/j.pec.2019.12.011","article-title":"The experiences and perspectives of family surrogate decision-makers: a systematic review of qualitative studies.","volume":"103","author":"Su","year":"2020","journal-title":"Patient Educ Couns"},{"issue":"12","key":"zoi251612r40","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.45608","article-title":"Conceptualization of surrogate decision-making among spokespersons for chronically ill patients.","volume":"5","author":"Van Scoy","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"6","key":"zoi251612r41","doi-asserted-by":"publisher","first-page":"1065","DOI":"10.1007\/s00134-016-4294-7","article-title":"Choice architecture in code status discussions with terminally ill patients and their families.","volume":"42","author":"Anesi","year":"2016","journal-title":"Intensive Care Med"},{"issue":"5","key":"zoi251612r42","doi-asserted-by":"publisher","first-page":"362","DOI":"10.1136\/bmjqs-2020-011801","article-title":"Choice architecture in physician-patient communication: a mixed-methods assessments of physicians\u2019 competency.","volume":"30","author":"Hart","year":"2021","journal-title":"BMJ Qual Saf"},{"issue":"3","key":"zoi251612r43","doi-asserted-by":"publisher","first-page":"306","DOI":"10.1089\/jpm.2014.0295","article-title":"Easing the burden of surrogate decision making: the role of a do-not-escalate-treatment order.","volume":"18","author":"Jacobsen","year":"2015","journal-title":"J Palliat Med"},{"issue":"7","key":"zoi251612r44","doi-asserted-by":"publisher","first-page":"545","DOI":"10.1001\/virtualmentor.2012.14.7.ecas3-1207","article-title":"The use of informed assent in withholding cardiopulmonary resuscitation in the ICU.","volume":"14","author":"Curtis","year":"2012","journal-title":"Virtual Mentor"},{"issue":"3","key":"zoi251612r45","doi-asserted-by":"publisher","first-page":"748","DOI":"10.1378\/chest.07-0745","article-title":"Point: the ethics of unilateral \u201cdo not resuscitate\u201d orders: the role of \u201cinformed assent\u201d.","volume":"132","author":"Curtis","year":"2007","journal-title":"Chest"},{"issue":"1","key":"zoi251612r46","doi-asserted-by":"publisher","first-page":"320","DOI":"10.1378\/chest.07-2392","article-title":"Informed nondissent rather than informed assent.","volume":"133","author":"Kon","year":"2008","journal-title":"Chest"},{"issue":"8","key":"zoi251612r47","doi-asserted-by":"publisher","first-page":"903","DOI":"10.1001\/jama.2010.1208","article-title":"The shared decision-making continuum.","volume":"304","author":"Kon","year":"2010","journal-title":"JAMA"},{"issue":"1","key":"zoi251612r48","doi-asserted-by":"publisher","first-page":"90","DOI":"10.1093\/jmp\/jhv035","article-title":"Medically inappropriate or futile treatment: deliberation and justification.","volume":"41","author":"Misak","year":"2016","journal-title":"J Med Philos"},{"issue":"4","key":"zoi251612r49","doi-asserted-by":"publisher","first-page":"320","DOI":"10.1164\/rccm.200811-1776OC","article-title":"Are physicians\u2019 recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate.","volume":"180","author":"White","year":"2009","journal-title":"Am J Respir Crit Care Med"},{"issue":"7","key":"zoi251612r50","doi-asserted-by":"publisher","first-page":"915","DOI":"10.1164\/rccm.201008-1214OC","article-title":"An empirical study of surrogates\u2019 preferred level of control over value-laden life support decisions in intensive care units.","volume":"183","author":"Johnson","year":"2011","journal-title":"Am J Respir Crit Care Med"},{"key":"zoi251612r35","volume-title":"Are Workarounds Ethical?: Managing Moral Problems in Health Care Systems","author":"Berlinger","year":"2016"},{"key":"zoi251612r7","unstructured":"Emanuel? EJ. My 92-year-old father didn\u2019t need more medical care. The Atlantic. January 2, 2020. Accessed September 16, 2025. https:\/\/www.theatlantic.com\/ideas\/archive\/2020\/01\/we-protected-my-terminally-ill-father-system\/604312\/"},{"key":"zoi251612r8","unstructured":"McConnell? K. The medical care that helps no one. The Atlantic. May 10, 2023. Accessed September 16, 2025. https:\/\/www.theatlantic.com\/ideas\/archive\/2023\/05\/icu-nurse-palliative-care-ventilators-intubation\/673984\/"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2845320\/batten_2026_oi_251612_1772648308.44668.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T18:30:27Z","timestamp":1772649027000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2845320"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,20]]},"references-count":50,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2026,2,2]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.60260","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,20]]}}}