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Zorluk: ZorEnd-of-Life and Palliative Care

An 81-year-old woman is evaluated on the medical ward on hospital day 3. She was admitted for severe aspiration pneumonia and sepsis. Her medical history is significant for advanced Alzheimer disease; she has been completely bedbound, doubly incontinent, and nonverbal for the past year. She currently requires high-flow oxygen, and her clinical trajectory suggests she may soon require mechanical ventilation if aggressive care is pursued. She does not have an advance directive or a legally appointed healthcare proxy.

The patient's daughter, who lives locally and visits her mother daily at the nursing facility, believes her mother would never have wanted her life artificially prolonged in her current state. She requests that the medical team focus exclusively on comfort measures. The patient's son, who lives in a different state and arrived this morning, vehemently disagrees. He insists that his mother is 'a fighter,' demands full resuscitation status, and requests the placement of a percutaneous endoscopic gastrostomy tube to prevent future aspiration. He states he will contact an attorney if everything possible is not done. In the state where the hospital is located, all adult children share equal priority in the surrogate hierarchy.

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

  1. A
    Proceed with intensive care unit transfer and gastrostomy tube placement to comply with the son's demands and avoid legal liability.
  2. B
    Implement comfort-focused care according to the daughter's wishes because she serves as the primary local caregiver.
  3. Request a clinical ethics committee consultation to help mediate the conflict and establish a consensus.Cevap
  4. D
    Order a psychiatric consultation to evaluate the son's decision-making capacity given his aggressive demands.
  5. E
    Arrange for immediate discharge to a hospice facility based on the daughter's verbal authorization.

Cevap

Request a clinical ethics committee consultation to help mediate the conflict and establish a consensus.
When there is a fundamental disagreement between co-equal surrogate decision-makers (in this case, two adult children) regarding the goals of care for an incapacitated patient, the medical team cannot unilaterally choose which surrogate to follow. Although the medical team may agree with the daughter's assessment that comfort-focused care is most appropriate for a patient with advanced Alzheimer disease, the daughter does not possess higher legal authority than her brother. The appropriate initial approach is to hold family meetings to facilitate consensus, typically with the assistance of a clinical ethics committee, palliative care specialists, or social workers. An ethics consultation can help clarify the patient's previously expressed values, mediate the interpersonal conflict, and guide the application of the substituted judgment standard.

Adım Adım Çözüm

1
Identify the patient's capacity and advance directive status.
The patient lacks decision-making capacity due to advanced dementia and acute illness, and she has no advance directive or designated proxy.
This establishes the clinical and legal requirement for surrogate decision-makers.
2
Determine the legal status of the available surrogate decision-makers.
Both the daughter and the son are adult children, placing them at the exact same priority level in the default legal surrogate hierarchy.
Understanding the legal hierarchy prevents the medical team from inappropriately favoring one surrogate over another based on subjective criteria.
3
Assess the conflict and determine the appropriate dispute resolution mechanism.
Because co-equal surrogates fundamentally disagree on the goals of care, an ethics committee consultation is required.
Physicians cannot unilaterally break a tie between co-equal surrogates; formal mediation is the standard of care to help apply the principle of substituted judgment.

Anahtar Kavram

Management of conflicts between co-equal surrogate decision-makers regarding end-of-life care
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Konular

End-of-Life and Palliative Care

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