Examkin

Question

Difficulty: MediumEnd-of-Life and Palliative Care

An 82-year-old man with a history of New York Heart Association class IV heart failure and severe peripheral artery disease is admitted to the intensive care unit with acute cardiogenic shock. He is currently receiving continuous intravenous infusions of norepinephrine and dobutamine. Despite these interventions, his extremities are cold and mottled, and his urine output is minimal. The attending physician informs the patient that without mechanical circulatory support, such as an intra-aortic balloon pump, he will likely die within hours to days.

The patient is fully alert, oriented to person, place, and time. He accurately repeats the clinical information back to the physician and states, "I have lived a long life and I do not want to spend my final moments hooked up to more machines. Please stop these blood pressure medications and just keep me comfortable."

Shortly after, the patient's adult daughter, who is designated as his legal healthcare proxy in a signed advance directive, arrives at the bedside. She insists that all life-sustaining measures be continued, stating, "He is just overwhelmed right now and not thinking straight. As his healthcare proxy, I authorize the mechanical support."

Which of the following is the most appropriate next step in the management of this patient?

  1. Discontinue the vasopressor infusions and administer medications targeted at symptom reliefAnswer
  2. B
    Continue the vasopressor infusions and consult cardiothoracic surgery for mechanical support
  3. C
    Request a court order to formally determine the patient's legal competence to refuse life-saving treatment
  4. D
    Arrange for immediate medical transport to an off-site residential hospice facility
  5. E
    Maintain the current vasopressor infusions and obtain an urgent psychiatric consultation to assess for depression

Answer

Discontinue the vasopressor infusions and administer medications targeted at symptom relief.
The correct answer honors the ethical principle of patient autonomy. This patient has demonstrated clinical decision-making capacity: he understands his diagnosis of cardiogenic shock, appreciates his poor prognosis without mechanical support, and clearly communicates a rational choice to focus on comfort rather than prolonging the dying process. A capacitated adult has the absolute right to refuse any medical intervention. A designated healthcare proxy (such as his daughter) only gains decision-making authority when the patient loses clinical capacity. Therefore, the physician is ethically and legally obligated to respect the patient's wishes, discontinue the unwanted vasopressors, and initiate appropriate palliative symptom management.

Step-by-Step Solution

1
Assess the patient's clinical decision-making capacity.
The patient is alert, oriented, and able to understand, reason, and communicate his choice regarding his terminal prognosis.
Capacity is the foundation of medical decision-making and determines whose consent or refusal is valid.
2
Evaluate the authority of the surrogate decision-maker (the daughter).
The daughter's status as a healthcare proxy is not currently active.
An advance directive and proxy designation only take effect when the primary patient loses clinical decision-making capacity.
3
Implement the capacitated patient's autonomous medical decision.
Vasopressors are discontinued and the focus of care shifts exclusively to comfort measures.
A capacitated adult has the ethical and legal right to refuse any intervention, including life-sustaining treatment, even if the refusal results in death.

Key Concept

A capacitated patient's autonomous refusal of life-sustaining treatment overrides the wishes of family members or designated healthcare proxies. Proxy authority is only invoked when clinical capacity is lost.
Estimated Time:1m 15s
Rate this question

Topics

End-of-Life and Palliative Care

More questions from this topic