A 74-year-old woman is brought by ambulance to the emergency department due to confusion. She is accompanied by her daughter, who lives with her. The patient was diagnosed with aplastic anemia a year ago. Her condition has responded poorly to immunosuppressive therapy and has required multiple blood transfusions. The patient is alert and oriented to person only; she is unable to respond to other questions. Complete blood count shows severe pancytopenia. The patient has an advance directive, signed 9 months ago, in which she designated a friend as her health care proxy. The friend is contacted by phone and tells the physician that the patient did not want to undergo any more blood transfusions. The patient's daughter adamantly insists that the patient receive a blood transfusion, saying, "I discussed it with my mother a few weeks ago, and we decided that she should have everything done to prolong her life." In deciding whether to perform the blood transfusion, which of the following should the physician consider to have the highest priority?
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A health care proxy is a surrogate decision maker specifically chosen by a patient to legally make health care decisions on that patient's behalf. Designation occurs when the patient is competent but remains inactive until the patient is incapacitated (eg, delirious, "alert and oriented to person only," "unable to respond").
The health care proxy is obligated to give instructions in accordance with the best estimate of what the patient would have chosen (ie, substituted judgment standard), reflecting deference to patient autonomy. Often, a patient will directly inform the health care proxy of specific interventions to withhold (eg, patient does not want "any more blood transfusions") based on personal beliefs or consideration of the risks versus benefits. Therefore, this designated health care proxy (ie, the friend) takes legal priority over all other decision makers to facilitate and respect the patient's individual, informed decisions.
In this case, even though the friend adhered to the substituted judgment standard by refusing the blood transfusion, there is an isolated report of a change in patient preference from the non–health care proxy daughter. However, this change would be difficult to confirm and is complicated by an unknown context (eg, incapacitated, guilt induced, coerced) in which the patient may have said this (Choice A). Although the reported change warrants further investigation with the health care proxy, the established health care proxy remains as the highest priority decision maker.
(Choice B) Nonmaleficence is the ethical duty to do no harm to the patient. However, the principle that guides a health care proxy in making medical decisions is the principle of patient autonomy, which emphasize the patient's own preferences that were made when decision-making capacity was intact.
(Choices D and E) The risks (eg, transfusion-related infection, allergic reaction) and benefits (eg, "a meaningful recovery") of any medical intervention should always be discussed with the patient or the patient's health care proxy. However, this patient has already communicated her decision to her health care proxy to decline more blood transfusions, which takes precedence.
Educational objective:
A health care proxy is a person legally designated to make medical decisions if the patient loses decision-making capacity. The health care proxy has more authority than all other surrogate decision makers and is expected to act in accordance with the best estimate of what the patient would have chosen.