Patient wishes, surrogate demands in conflict
Attempted suicide muddies the dilemma
The situation: The 53-year-old man was brought to the hospital’s emergency department after suffering a gunshot wound to the head. The wound was thought to be self-inflicted. The man had been disabled for more than 10 years. He was bedridden and constantly complained of pain. The man had completed an advance directive and named his wife as his surrogate decision maker.
Shortly after the patient’s arrival in the emergency department, he was placed on a mechanical ventilator to treat edema in the neck and was taken to surgery. The injury has caused considerable damage to his face and head but only the frontal lobes of the brain. Surgeons surmised there would be minimal brain damage with no neurologic motor or sensory deficit. He was expected to be extubated shortly after swelling in the neck subsided and he could breathe on his own.
At the same time, the patient’s wife showed the medical team her husband’s advance directive written three months prior that named her as his surrogate. She demanded that all emergency treatment be stopped, including artificial respiration, and that he be "allowed to die."
The man had suffered severe emotional and physical pain for some time and would not want to be kept alive, she said. The durable power of attorney for health care stated that he did not wish to be kept alive by artificial means but in his own handwriting had this additional caveat "if I am hopeless."
The consultation and discussion: The ethics committee met to discuss the case and was struck by the patient’s written words and the seeming contradiction between these words and the wishes expressed by the spouse, the physician who chairs the ethics committee explains.
"The physicians and surgeons told us that his condition clearly was reversible," the physician says.
The advance directive further stated: "If the extension of my life results in mere biologic existence, devoid of cognitive function, I do not desire any form of life-maintaining procedures. My agent should ask the question, Is the proposed treatment an aid to recovery or merely a prolongation of inevitable death?’ I desire that my agent act after a reasonable time for observation and diagnosis."
The committee met with the family members for nearly three hours. All family members were insistent that the patient be removed from life support and allowed to die. Doctors felt that he would die, in fact, if discontinued from ventilator support too soon.
"As the chair of the hospital’s ethics committee, it is not terribly uncommon to see a situation where a surrogate’s decision seems to conflict with the patient’s wishes," the doctor says. This generally occurs when the wording of the directive is limited or vague. The wife told the committee that the writing in the directive was simply "boilerplate language" that had been given to him.
The committee members wondered: Were they being too cautious? One committee member asked the surrogate if the patient’s wishes seemed like those of someone who would want to die when they could be kept alive. The wife said that she knew her husband’s true wish was to die. She said the directive, in which the patient wanted to die only if the situation was "a prolongation of inevitable death," was made several years ago, although signed recently. His wishes had changed, the wife maintained.
The ethics committee had one more concern: Were the surrogate and the family really asking the hospital to "complete" a failed suicide? How did a supposedly bed-ridden patient get a gun to shoot himself? Why did the family call 911 if they believed he wanted to die? Should the ethics committee be concerned that the surrogate did not have the patient’s best wishes at heart? Should they report their concerns to the police?
The committee decided not to contact police at that time and recommended that life support be maintained.
The conclusion: Family members did not accept the committee’s recommendation. Hospital policy stated that under this type of situation, a patient could be transferred to another hospital. Since the determination was made late on a Friday, the receiving hospital agreed that the transfer could take place early Monday morning. On the way to the second hospital via ambulance, the patient opened his eyes. When staff asked him if he wanted to be kept alive, he indicated that he did.
The patient was subsequently weaned from the ventilator and is recuperating in a rehabilitation facility. With the front lobes of the brain destroyed, the patient no longer complains of pain and a previously diagnosed chronic depression has been remedied.
The retrospective review: The ethicist for the hospital’s affiliated system ethics program says a committee review of the case brought several important questions to light:
• What ethical principle was more important preserving the patient’s wishes or following the authority of the surrogate given by the patient?
• Can a surrogate decision maker "interpret" a patient’s wishes if he or she thinks it is consistent with the patient’s desires, or is the surrogate bound by what the directive actually says?
• If the hospital had complied with the family’s wishes, would this have been viewed legally as physician-assisted suicide?
• What role does an ethics committee have in reporting suspected abuse? Should the ethics committee have asked the family about its concerns despite the fact that police had cleared the wife of any wrongdoing?
[Editor’s note: What are your thoughts about this difficult case and the questions it raises? Write us with your response: Medical Ethics Advisor, American Health Consultants, P.O. Box 740056, Atlanta, GA 30305. Or fax to Kevin New, associate editor of Medical Ethics Advisor, (404) 262-7837. E-mail: [email protected].]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content