Making care decisions for patients who can’t
2 situations lead to different conclusions
Situation No. 1: A 38-year-old-man was brought to the emergency department by ambulance. He had been found comatose on the streets of Dallas. Although he had identification, no family members could be found. Apparently he had been homeless for some time and had suffered the complications of a major electrolyte imbalance. The police were notified, and hospital social services staff began the laborious process of trying to find a family member or friend.
After a month, no one who knew the man now in a persistent vegetative state could be found. The prognosis was that the man could be in a vegetative state for some time or could die soon.
The ethics committee discussion: "Our committee was consulted when it became apparent that the patient was not going to wake up," says Robert Fine, MD, an internist and chairman of the institutional ethics committee at Baylor University Medical Center in Dallas.
"We had policies for withdrawal with the consent of a surrogate but no guidance on what to do in this circumstance," he explains.
With the approval of the hospital’s legal counsel, the ethics committee discussed the man’s situation in light of a reasonable person standard, says Fine. "We ask, given the typical young male who was in a persistent vegetative state, would this man want to be kept alive?" he says.
The committee concluded that life support should be withdrawn in this situation.
Situation No. 2: A 29-year-old woman with severe mental retardation was brought to the emergency department from a nursing home suffering from a severe urinary tract infection. She developed kidney failure, required dialysis, and soon slipped into a coma-like state. The woman’s parents were quite elderly (in their 70s and 80s) and had signed over her care to the state. Now they had no legal authority to withhold or withdraw care or ask that a do-not-resuscitate (DNR) order be written. The woman suffered cardiac arrest and was resuscitated.
The ethics committee discussion: The entire ethics committee, including the hospital’s legal counsel, met to discuss the patient’s case. Staff were frustrated and concerned that DNR order could not be written because the state had no authority to consent, either.
"Ethically, we did not feel [a DNR order] was a problem," says Wayne Anderson, director of pastoral care at Castle Medical Center in Kailua, HI. Still, the committee agonized over the issue: "Who was in charge of this woman’s care, and when was it appropriate to say we had gone far enough?" The parents agreed with the care team’s assessment but could not authorize a DNR order.
"The parents were attentive to her but wanted to let her go," he says.
After coding six times, the patient finally died of cardiac arrest after three months in the hospital.
Retrospective review: Both cases illustrate the need for clearer policies regarding patients without a specific surrogate decision maker. The second case demonstrates that state guardianship of a patient does not necessarily mean that the best interests of the patient will be followed or that the state knows the patient’s wishes or the family’s values.
Following the Baylor case, the institutional ethics committee revised its policy on withdrawal of life-sustaining treatment. The policy now includes a provision that if a physician determines that life-sustaining treatment should be withdrawn and there is no surrogate, the ethics committee must be consulted and approve the withdrawal.
In some cases, this built-in delay has forced the staff to look even more earnestly for a relative or friend, and sometimes one has been located, Fine says. The committee looks for other indications of the patient’s wishes, such as known religion or conversations with an acquaintance.
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