Examkin

Question

Difficulty: MediumEnd-of-Life Care Ethics

A 62-year-old man with advanced amyotrophic lateral sclerosis is evaluated in the progressive care unit. He was admitted two days ago for worsening hypercapnic respiratory failure and currently requires continuous noninvasive positive-pressure ventilation (NIPPV) to maintain normal mentation and oxygenation. The patient communicates effectively using an eye-tracking augmentative device. While being examined by the medical team, he explicitly states, 'I cannot live like this anymore. Please turn off the machine and give me something for the breathlessness.' His wife is present, becomes highly distressed, and tells the physician, 'You cannot do this! The infection is clouding his mind. You must get a judge to rule on his legal competence before you let him make a decision to die.' The physician subsequently performs a thorough evaluation of the patient. The patient correctly states his diagnosis, understands the life-sustaining purpose of the NIPPV, and clearly articulates that stopping the machine will lead to his death. He consistently expresses a rational desire to avoid further prolongation of his dying process. He displays no signs of delirium, and a recent arterial blood gas analysis confirms the resolution of his prior hypercapnia. Which of the following is the most appropriate next step in management?

  1. A
    Request a judicial hearing to formally establish the patient's legal competence to refuse care.
  2. B
    Transfer decision-making authority to the patient's wife as his default surrogate decision-maker.
  3. Discontinue the noninvasive positive-pressure ventilation and initiate an intravenous opioid infusion.Answer
  4. D
    Arrange for immediate transfer to an inpatient hospice facility while maintaining noninvasive ventilation.
  5. E
    Postpone the decision and obtain a psychiatry consultation to evaluate for underlying depression.

Answer

Discontinue the noninvasive positive-pressure ventilation and initiate an intravenous opioid infusion.
The correct answer is to discontinue the noninvasive positive-pressure ventilation and initiate an intravenous opioid infusion. A patient with decision-making capacity has the ethical and legal right to refuse any medical intervention, including life-sustaining treatments like NIPPV. In this vignette, the attending physician correctly assesses that the patient understands his condition, the treatment, and the terminal consequences of his decision. Therefore, his autonomous request must be honored. In conjunction with withdrawing life support, the physician is obligated to provide comprehensive palliative care, which includes utilizing opioids to manage the expected terminal dyspnea and ensure comfort.

Step-by-Step Solution

1
Assess the patient's decision-making capacity regarding his request to withdraw life support.
The physician determines the patient understands his diagnosis, the purpose of the treatment, and the fatal consequence of withdrawing it.
Capacity is the primary requirement for a patient to refuse life-sustaining therapy.
2
Evaluate the wife's demand for a legal competence ruling and surrogate authority.
The demand is overruled.
Physicians determine capacity, not judges. Surrogates only gain authority when the patient lacks capacity.
3
Implement the patient's autonomous decision while providing end-of-life symptom control.
NIPPV is withdrawn, and opioids are administered for dyspnea.
Ethical principles dictate that capable patients have the right to refuse any medical intervention, and physicians have a duty to palliate symptoms during the dying process.

Key Concept

Patient Autonomy, Decision-Making Capacity, and the Right to Refuse Life-Sustaining Treatment
Rate this question

Topics

End-of-Life Care Ethics

More questions from this topic