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Difficulty: EasyInformed Consent and Refusal of Care

A 71-year-old man is brought to the emergency department after collapsing at home. He is unresponsive, and a CT scan of the head reveals a massive, irreversible intracranial hemorrhage. The neurology team determines that he will not regain consciousness. The patient currently requires intubation for airway protection. The patient's adult son is at the bedside and tearfully insists that his father be intubated and placed on mechanical ventilation. However, the medical record contains a legally valid advance directive executed two years ago, designating the patient's long-time neighbor as his healthcare proxy. The neighbor arrives at the hospital, presents a copy of the directive, and states that the patient strongly valued quality of life and would never want to be kept alive on a ventilator, requesting comfort measures only. Which of the following is the most appropriate next step in management?

  1. Withhold intubation and initiate comfort measures as directed by the neighborAnswer
  2. B
    Intubate the patient because a biological child's medical decisions supersede those of a non-relative
  3. C
    Intubate the patient temporarily to preserve life while referring the case to the hospital ethics committee
  4. D
    Require the son and the neighbor to reach a unanimous decision before proceeding with any intervention
  5. E
    Seek an emergency court order to transfer decision-making authority to the son

Answer

Withhold intubation and initiate comfort measures as directed by the neighbor.
The most appropriate next step is to follow the instructions of the legally appointed healthcare proxy. When a patient loses decision-making capacity, medical decisions must be guided by their advance directive or a designated healthcare proxy (durable power of attorney for healthcare). A legally designated proxy supersedes biological relatives (next-of-kin) in the surrogate decision-maker hierarchy. Since the patient formally appointed his neighbor as his proxy, the neighbor's decision to pursue comfort measures must be respected over the son's request for intubation.

Step-by-Step Solution

1
Determine the patient's decision-making capacity.
The patient is unresponsive and lacks capacity.
Capacity must be assessed to determine if a surrogate is needed.
2
Identify the appropriate surrogate decision-maker based on the legal hierarchy.
The neighbor is the legally designated healthcare proxy.
A designated proxy through an advance directive holds the highest priority, superseding default next-of-kin such as a biological child.
3
Implement the medical decision made by the appropriate surrogate.
Comfort measures are initiated.
The proxy's decision accurately reflects the patient's documented wishes and holds legal authority.

Key Concept

Hierarchy of Surrogate Decision-Makers
Estimated Time:45s
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Topics

Informed Consent and Refusal of Care

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