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As the surgical resident covering the emergency department, you are called to see a 78-year-old nursing home resident with severe dementia, labored breathing, a cold leg, and a blood pressure of 70/40. As you prepare to talk to the family about palliative care, his saturation drops to 60%. His family including eight children tell you that they want “everything done” because they know that their grandfather wants to live. What is the next step in management?

The patient should be intubated. This action is not medical futility because the ventilator provides oxygen and ventilation so the patient can breathe. It is not unnecessary pain and suffering because there are medications to relieve pain and suffering. It is not poor quality of life because quality of life is unknown and the desaturation could be very transient. It is not related to cost effectiveness because in the United States cost is not a factor in providing care to a patient in the emergency department.

Ethical Principles for Medical Decision Making

•Autonomy

•Nonmaleficence

•Beneficence

•Utility

•Distributive justice

Autonomy

•Self-determination

•A rational person is uniquely qualified to decide what is best for them

•A person should be allowed to do what they want even if it involves doing something others might view as foolish

•Respect for autonomy led to the development and requirement of informed consent procedures

•A competent individual has the right to refuse any treatment

Nonmaleficence

•The duty of a physician to not provide a treatment known to be ineffective

•A form of refraining from inflicting harm

•This is a daily issue when offering therapies, surgical procedures, and basic medications

•Most surgical procedures are fraught with risk and yet little is known about the benefits of some

Beneficence

•Requires positive actions to prevent evil or harm

•Physicians are trusted experts that are to act in the patient’s best interest

•Providers are expected to make reasonable sacrifices for their patients

Utility

•Promotes the greatest benefit to the greatest number of individuals

•Fairness to individuals is compromised when focusing exclusively on a majority

•When trying to provide the most possible good to the community, some individual needs will not be met

Distributive Justice

•The concept of fairness among individuals

•Cases ought to be treated in a similar fashion

•Benefits and burdens should be equally shared within a society

•Goods should be distributed according to need

•Individuals should be rewarded for contributions made

An 81-year-old man with widely metastatic duodenal cancer underwent an exploratory laparotomy with intestinal bypass for obstruction. Days later, he develops shortness of breath on the floor and is transferred to the ICU. He is in minor distress and is unable to give consent. His advance directive states that he does not want any heroic measures or to be in a persistent vegetative state. His family is not present or immediately available. Would you intubate this patient?

There are two reasonable options in this situation which meet the goals of ethical care

•Intubate the patient for a trial of 5 to 7 days to see if he improves on mechanical ventilation, during which time his wishes can be clarified with him and/or his family.

•Refrain from intubation if you believe this is what the patient wishes, based on your relationship with him.

•Requires several physicians to document that mechanical ventilation will not benefit the patient

•Continue to provide comfort therapy

“For a patient with metastatic cancer and liver failure, respiratory support on a ventilator does not even have to be offered because it will only prolong a death rather than provide treatment of the disease.” –Hening, 2001

The Advance Directive

•Completed in case a person becomes incapacitated and unable to participate in treatment decision making

•Three objectives

•To maintain patient autonomy through “anticipatory decision making”

•To help guide therapy in end-of-life circumstances by assigning a decision maker, thus avoiding the need for judicial involvement

•To grant medical providers immunity from civil and criminal liability

The Living Will

•One form of an advance directive in which a competent adult can address his or her wishes for future specific medical therapies, should he or she become incompetent

•Specifies the life-prolonging measures an individual wants and does not want taken on his or her behalf in the event of a terminal illness

The Healthcare Proxy

•Sometimes referred to as a durable power of attorney for healthcare matters

•An individual designates an individual, usually a relative, or a close personal friend, to make health care decisions for someone when that person loses the capacity to make his or her own medical treatment decisions

•Can apply to any situation (not just terminal illnesses) in which an individual is incapable of making decisions

Statutes governing advanced directives, living wills, and healthcare proxies are determined by individual states. It is important to know the statutes in the state in which you practice. A hospital ethics, legal, or risk management office can help clarify state laws and hospital policies.

An 85-year-old male who sustained a motor vehicle crash arrives to the emergency department with extensive pelvic and facial fractures. He “codes” in the CT scanner, and CPR is performed for 20 minutes. He is transported to the ICU where he is on two vasopressors with a systolic blood pressure in the 70s after appropriate volume resuscitation. His family states that they “want everything done.” What is the next step in management?

While continuing current management, hold a family meeting during which the family is presented with the patient’s prognosis. In an open discussion, clarify what the family means by wanting “everything done.”

Principles of Family Care

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