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Difficulty: MediumInformed Consent and Refusal

A 74-year-old man is admitted to the intensive care unit with severe septic shock secondary to pneumonia. He is intubated, sedated, and lacks decision-making capacity. The critical care team determines that he requires initiation of continuous renal replacement therapy due to worsening acute kidney injury. A review of the medical record reveals no advance directive or designated healthcare power of attorney. Several family members and individuals close to the patient are present in the waiting room and have conflicting opinions regarding his care. The physician must obtain informed consent from the appropriate legally authorized representative. According to the standard legal hierarchy for surrogate decision-makers in most jurisdictions, arrange the following individuals from highest priority (first) to lowest priority (last) to provide informed consent.

  1. 1The patient's legally married wife
  2. 2The patient's 48-year-old biological daughter
  3. 3The patient's 92-year-old father
  4. 4The patient's 70-year-old brother
  5. 5The patient's long-term close friend and neighbor

Answer

The correct sequence from highest to lowest priority is: the patient's legally married wife, followed by the adult daughter, the father, the adult brother, and finally the close friend.
In the absence of a designated healthcare power of attorney (proxy) or a court-appointed legal guardian, medical professionals must rely on standard jurisdictional default hierarchies to identify a surrogate decision-maker for incapacitated patients. While specific laws vary slightly by state, the universally accepted standard order is: 1) Spouse, 2) Adult children, 3) Parents, 4) Adult siblings, and 5) Other adult relatives or close friends. Therefore, the physician must first seek consent from the legally married wife. If she is unavailable or incapacitated, the authority falls to the adult daughter, then the father, then the brother, and lastly the friend.

Step-by-Step Solution

1
Assess the patient's clinical state and ability to make medical decisions.
The patient lacks decision-making capacity due to sedation and intubation for severe septic shock.
Informed consent must be obtained from a surrogate only when the patient themselves is incapacitated.
2
Check the medical record for previously established directives or designated proxies.
No advance directive or designated healthcare power of attorney was found.
A patient-appointed proxy always supersedes the state's default legal hierarchy. Without one, the default hierarchy applies.
3
Apply the standard state default surrogate hierarchy to the available individuals.
The hierarchy mandates approaching the spouse first, then adult children, parents, adult siblings, and finally close friends.
To legally obtain informed consent for the continuous renal replacement therapy and ensure the patient's likely wishes are represented by the most legally appropriate proxy.

Key Concept

Standard legal hierarchy of default surrogate decision-makers for adult patients lacking capacity
Estimated Time:1m 30s
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Topics

Informed Consent and Refusal

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