Examkin

Question

Difficulty: HardInformed Consent and Refusal of Care

An 82-year-old woman is brought to the emergency department from an assisted living facility with severe diffuse abdominal pain, fever, and confusion. Her blood pressure is 85/50 mm Hg, and her pulse is 115/min. Physical examination reveals a rigid abdomen with severe rebound tenderness. A CT scan of the abdomen shows free air under the diaphragm, consistent with a perforated viscus. The surgical team determines that she requires an emergency exploratory laparotomy. The patient is lethargic, oriented only to her name, and unable to demonstrate understanding of her clinical condition. Her medical chart includes an advance directive that appoints her eldest son as her sole healthcare proxy, but it does not specify her wishes regarding life-sustaining treatments or major surgery. The attending physician contacts the eldest son by phone. The eldest son states, "I cannot handle this responsibility right now, you need to ask my younger brother," and immediately hangs up. The younger brother is present at the bedside and states, "My mother and I talked about this exact scenario last month. She explicitly told me she would never want major surgery or life support if she got severely ill. Please just keep her comfortable." Which of the following is the most appropriate next step in management?

  1. Withhold the exploratory laparotomy and provide appropriate palliative measuresAnswer
  2. B
    Proceed with the exploratory laparotomy under the doctrine of implied consent
  3. C
    Proceed with the exploratory laparotomy because the younger brother is not the legally designated proxy
  4. D
    Delay the intervention to make further attempts to involve the eldest son in the decision
  5. E
    Obtain an emergency court order to determine the appropriate surrogate decision-maker

Answer

Withhold the exploratory laparotomy and provide appropriate palliative measures
The correct approach is to withhold the exploratory laparotomy and provide appropriate palliative measures. This patient lacks decision-making capacity due to her critical illness and delirium. While she has an advance directive naming her eldest son as her proxy, he explicitly declined to accept the responsibility. When a designated proxy abdicates their role or is permanently unavailable, decision-making authority defaults to the next available individual in the state's legal surrogate hierarchy (typically spouse, followed by adult children). Therefore, the younger brother legally assumes the role of surrogate decision-maker. Under the ethical principle of substituted judgment, a surrogate must make the healthcare decision that the patient would have made if they were competent, based on their previously expressed wishes or known values. Because the younger brother is conveying the patient's explicitly stated wish to avoid major surgery or life support in this exact scenario, the medical team is legally and ethically obligated to honor her refusal, even in a life-threatening emergency.

Step-by-Step Solution

1
Assess the patient's decision-making capacity.
The patient lacks capacity due to lethargy and confusion resulting from septic shock.
Capacity must be determined before relying on surrogate decision-makers.
2
Identify the legally authorized surrogate decision-maker.
The eldest son (designated proxy) abdicated his responsibility, transferring authority to the younger brother (next-of-kin).
When an appointed proxy declines to act, standard statutory hierarchies (e.g., other adult children) dictate who becomes the surrogate.
3
Evaluate the surrogate's directive against ethical standards.
The younger brother is exercising substituted judgment based on the patient's explicitly stated prior wishes to avoid major surgery.
Surrogates must base decisions on the patient's known values. A valid refusal must be honored even if it directly leads to death.

Key Concept

When a legally appointed healthcare proxy declines to act, decision-making authority defaults to the next available individual in the statutory surrogate hierarchy, whose substituted judgment based on the patient's prior wishes must be honored.
Rate this question

Topics

Informed Consent and Refusal of Care

More questions from this topic