•A 67-year-old woman has suffered a massive subarachnoid hemorrhage. The patient was well until three days prior when she had a sudden loss of consciousness. After emergent transport to the local hospital where her trachea was intubated and a CT scan disclosed a large grade 4 subarachnoid bleed, she was transferred to the intensive care unit. Over the past 72 hours her condition is unchanged. She in nonresponsive to deep painful stimulus, there is no dolls’ eye or gag reflex, and corneal blink reflex is absent. She has had no narcotics, analgesics, or paralytics. There is discord present within the family about whether to withdraw care. The husband desires care to be withdrawn whereas the children want to continue maximal supportive care. You explain that the most important determining factor in helping to direct future care is
A. the decision of a court appointed legal guardian •
B. the decision of the medical and nursing team taking care of the patient •
C. the husband’s wishes given that he is the health care proxy •
D. the opinion of the hospital ethics committee •
E. the patient’s previously expressed wishes regarding life support if known
e
archer when will u post the answers?
B . the decision of the medical and nursing team taking care of the patient •
Subject is brain dead.
i would like to know the answers for the questions…..when will u post them archer??
e
E
e
B
eeeeeeeeeeeeee
E
please post the answer.
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE
Answer is E.
In these difficult situations where the patient is not able to make their own decisions and when there is disparate views among family members, the most important directing factor should be what the patient would have decided were they able to speak for themselves. Therefore, previously expressed views on what the patient would want if faced with a similar situation could prove invaluable in helping to direct care in the direction that the patient would have wanted. Court appointed legal guardians (choice A) are utilized when a patient has no family or has family members who are not competent to help make medical decisions on behalf of the incapacitated patient. If the patient has a clearly expressed view, this view would supercede any sentiments by the medical team (choice B), the husband (choice C), or a hospital ethics committee (choice D).
a ‘clearly expressed view’ required definition.
Many hospitals WILL NOT accept a statement of ‘she said…..” They require previously submitted or legally signed directives. Next best thing is next of kin, husband.
eee
The answer of Dr. Red unfortunately may be incorrect, because the patient is brain dead. Whatever the discord among the patient’s family members, still the supportive measure should be withdrawn but there should be a discussion with the family, because this is a futile work. Suppose the family members discussed the issue among them and arrive to coordinated decision that they want the supportive measure to be continued. It is not acceptable to keep a brain dead on the supportive measures indefinitely. No one of the insurance company pay for supportive measures for a brain dead patient.
Or suppose that the patient wishes are to keep the supportive at its maximum. There is no point of continuing a supportive care for a brain dead patient even if he expressed a wishes for continuing life support. In this case the decision is for the medical staff.
The question is not testing the concept of medical futility. And the question does not mention whether patient’s wished for continuing care further or DNR. Before you decide to proceed on basis of medical futility, you must look at what patient has in place – a living will or previously expressed wishes. If these wishes says “DNR”, your job becomes easy and you can proceed legally without bringing in the concept of “futility” . If by chance his wishes says to do “everything”, then you go to your next step and withdraw care based on “futility”.
Clearly, the question gave the picture of brain death. Then I do not need to know if DNR present or not, because it will not affect my decision. I know exactly what principle you are explaining, but to answer MCQ question, we have to choose the best possible answer which, I think, is not the patient’s expressed wishes for this question. You may change the question to fit what do you want to explain. Thanks
Medical team can only propose to discontinue care based on “futility”. You can not go and withdraw life support immediately without discussing with the patient’s family or without satisfying the procedure involved in declaring a case futile . Because patient’s family always has an option to “obtain an ethics consult” or “to transfer to another facility”, you must give them those options – we are not dictators, we can refuse care based on futility grounds but we can not object if the family wants to take the patient to a different facility.
Note this : “When the attending physician has documented these futility
determinations in the patient’s medical record, and another attending physician,
after examining the patient, has reached the same medical conclusions and
similarly has documented this agreement in the patient’s medical record, the
patient’s attending physician is under no obligation to initiate or to continue such care.
When a decision has been made that the requested
treatment or intervention is futile based on the above criteria and that
determination has been confirmed by another physician with appropriate expertise
who has no prior or present relationship with the patient, the patient or the
patient’s representative(s) shall be so informed. If the patient or the patient’s
representative(s) disagree with the decision to withdraw or not to initiate futile
intervention, the patient/family/representative should be referred to the Ethics
Committee and given the opportunity to secure the services of another physician.
The family should be supported in their efforts to secure services of another
physician, if that is their wish. ”
So, the most helpful immediate factor that helps in deciding on the care is still Option E. Option B is a process not something that can be done by one physician – Option B also requires another physician NOT INVOLVED in direct care of patient to attest and agree with attending doctor that the care is futile
I have to disagree. The health care proxy or husband is the person to turn to for an answer. This assumes the document is in the patient record. No one else has the right to speak or make decisions for an incompetent patient unless it is through the court system. If I were health proxy for my spouse and the hospital followed a course of action determined by another family member or a staff nurse? unless I was not available this is not ethical or per standard.