| The following vignette applies to the next 2 items. |
A 72-year-old man is brought to the emergency department (ED) due to a sudden onset of severe difficulty in breathing. He has chronic obstructive pulmonary disease, and is on 2 liters of oxygen at all times. While in the ED, he develops progressive hypoxic respiratory failure, and is intubated by the ED physician. His son comes to the hospital an hour later and gets very upset. He pulls you to one side of the room and says, "Please remove the tube. He never wanted to live like this." The patient does not have any advance directives for his health care. He regains consciousness for a few seconds while you are having a discussion with his son, but he is unable to state his wishes regarding life-sustaining treatment.
Item 1 of 2
Which of the following is the most appropriate next step in the management of this patient?
Physicians are often faced with difficult scenarios involving the withdrawal of life-sustaining treatment. The situation may arise when a patient is rendered incompetent or is unable to participate in decision-making, and does not have any advance directives. In such situations, the physician must still recognize and respect the patient's autonomy and right to make healthcare decisions. It is the physician's responsibility to act in the patient's best interest by identifying a surrogate who must make healthcare decisions for the patient based on substituted judgment. The surrogate speaks on the patient's behalf, and must have the most knowledge on what the patient would have done or wanted if he were able to make his own healthcare decisions. The patient's spouse or next of kin usually acts as the surrogate decision-maker in the absence of a formally or legally designated surrogate.
The patient's son appears to have some insight into his father's wishes when he claimed that "he would have never wanted to live like this." The patient may have previously expressed his wishes regarding life-sustaining treatment to his son. The son should therefore be asked to provide more information and reasoning behind the decision to withdraw mechanical ventilation at this point.
(Choice A) Telling the son that mechanical ventilation cannot be discontinued without an advance directive is incorrect. The son can assume the role of surrogate decision-maker as long as the physician believes that he is acting in the patient's best interest.
(Choice B) The physician should discuss the situation with the son in greater detail before involving the family.
(Choice D) Understanding the reason and thoughts behind the son's opinion should be attempted to ascertain if he can act as the patient's surrogate decision maker. Once a surrogate is identified, the decision to withdraw or maintain ventilatory support can then be made.
(Choice E) Involvement of the hospital ethics committee is not required at this point.
Educational objective:
Before making any decisions regarding the withdrawal of life support measures, it is important for physicians to act in the patient's best interest by identifying a surrogate, with whom they must effectively communicate and discuss all issues and concerns.