Ethics Case #1: A Case of Living Will with Multi-organ Failure

***Namrata Patil, MD MPH, Director, Thoracic Intermediate Care Unit, Brigham and Women’s Hospital, Harvard Medical School, Boston.
***Martha Jurchak, RN PhD, Director, Ethics Service, Brigham and Women’s Hospital, Boston

A 79 years old woman, a retired nurse, was transferred to a tertiary care academic medical center from an outside inpatient facility for the management of esophageal perforation. The patient had undergone resection of an esophageal diverticulum at the outside facility and then suffered the perforation complicated by ongoing leak. Patient was reported to be in reasonably good health before her initial elective surgery. She was living with her husband and caring for him as he was in early stages of dementia.  An esophageal stent was placed on arrival to the new facility for treatment of the perforation.  Unfortunately, subsequent to this procedure, the patient suffered septic shock resulting in multiple organ failures including respiratory failure with a need for prolonged mechanical ventilation, acute renal failure requiring hemodialysis, a continued need for vasopressors and delirium.  No additional surgical procedures were deemed appropriate to help improve patient’s status. In addition, the patient continued on tube feedings.

Patient had a living will that stated that if she "were in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery" she would want her physician "to withhold or withdraw treatment that merely prolongs her dying." She indicated that she especially did not want cardiac resuscitation, mechanical respiration, or artificial feeding."

Patient had retired as a nurse. Her designated Health Care Proxy was her son. He had to travel an hour each way to the hospital to see her and he cared for his father but he visited at least weekly. His sister visited more frequently. The son felt that he was violating his mother’s wishes but was hopeful that the condition his mother was in was temporary based on the surgeon’s promise for speedy and complete recovery. The daughter was acting on her own wishes to see her mother alive. The patient had a tracheotomy and would try to mouth words that were legible. Patient was evaluated by a psychiatrist who concluded that the patient had fluctuating, subacute delirium but there were times when she was capable of making decisions.

The provider team was divided on treatment recommendations. The attending surgeon thought that there may still be a chance for the patient to “pull through”. The intensivist and the nursing staff believed that her increasing organ system failures predicted her inevitable demise and that it was inappropriate to escalate or prolong the care: in effect that they were now acting against patient’s wishes.

In addition, during her lucid moments, the patient had expressed her wishes of having had enough and that she wanted to stop treatment. However, the daughter would persuade the patient into saying what the daughter wanted when she visited. The daughter was clearly struggling with the prospect of losing her mother.  The patient’s son and husband were starting to feel guilty that they were violating the patient’s wishes while pursuing tube feedings, continued ventilator support and dialysis for a prolonged period.

Questions: Please select the best option:

1. What obligations do the team members have towards making a single recommendation to the family?
   1. Individual care providers on the team have no responsibility to present a single recommendation to the family.
   2. The team members have only individual responsibility to recommend what they think is in the best treatment of the patient.
   3. The team has an obligation to work collectively in the patient’s best interest.
   4. The team is legally required to make a single recommendation at this time.
2. What responsibility does the team have for assessing this patient’s choice for herself?
   1. The team should go to court to assess the legitimacy of the patient’s choice.
   2. The team should accept family’s decision as the patient’s decision.
   3. The team should accept patient’s living will as her choice and make decisions based on that without asking the family’s decision.
   4. The team has a responsibility to assess patient’s decision-making capacity using expert consultation from psychiatrist to assess the patient’s understanding of his/her situation and their choices for treatment.
3. What is autonomy?
   1. Autonomy is the obligation to involve the family in all decision making.
   2. Autonomy is the right of children to decide what is best for their parents.
   3. Autonomy is the ethical principle that means “self-rule”
   4. Autonomy means that physicians can make decisions for their patient if the   patient cannot.
4. What is the difference between a living will and healthcare proxy?
   1. There is no difference between a living will and health care proxy.
   2. A living will is an “instructional” type of advanced directive and a healthcare proxy is transfer of authority to another person to speak for a patient lacking decisional capacity on healthcare matters only.
   3. A living will requires an attorney and a healthcare proxy requires going to court.
   4. A living will is a document regarding financial matters and a health care proxy is for healthcare related decisions.

Answers:

1.  c: Explanation: Team members may not agree among themselves but they have an obligation to attempt to resolve their differences. They should reach a consensus to offer a treatment plan that is clinically indicated and consistent with patient’s preferences. This is based on the model of shared decision making that reflects an enactment of the ethical principles of autonomy, beneficence, and non-maleficence. Since no medico-legal proceedings have been undertaken at this time, no legal obligation exists, except providing the appropriate management.

2. d. Explanation: The ethical principle of autonomy obligates healthcare providers to respect the wishes of a patient who is considered capable of making decisions. It is the obligation of the clinicians to assess decisional capacity. If this capacity is absent, then the clinician should turn to the legally designated decision maker to provide guidance based on the patient’s known wishes or if unknown, what they understand the patient would want for him/herself.

3. c. Explanation: Autonomy is the ethical principle, reflective of American societal value of liberty and reflective of free will, which requires that we respect the choices and values of others. In this case it refers to patient’s autonomy and not to the providers. This principle of ethics instructs providers to respect patient’s preferences and wishes regarding their care.

4. b. Explanation: A living will is an instructional advanced directive, written by the patient at a time of competence and free of duress, which instructs providers as to the patient's preferences in the event of an illness which impedes their ability to speak for themselves. A health care proxy is another person chosen and designated by the patient to make decisions regarding health care should the patient become unable to make decisions; this person is supposed to know the patient’s preferences and must be appointed by the patient before becoming incapacitated. Neither of these instruments requires the patient to obtain an attorney or go to court.

References:

1. Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors. Studdert DM, Mello MM, Burns JP, Puopolo AL, Galper BZ, Truog RD, Brennan TA. Intensive Care Med. 2003 Sep;29(9):1489-97
2. Consultants' conflicts: a case discussion of differences and their resolution. Caplan JP, Epstein LA, Stern TA. Psychosomatics. 2008 Jan-Feb;49(1):8-13
3. An integrated approach to ethical decision-making in the health team. Botes A. J Adv Nurs. 2000 Nov;32(5):1076-82.
4. Beyond autonomy: diversifying end-of-life decision-making approaches to serve patients and families. Winzelberg GS, Hanson LC, Tulsky JA.  J Am Geriatr Soc. 2005 Jun;53(6):1046-50.
5. A history of resolving conflicts over end-of-life care in intensive care units in the United States. Luce JM. Crit Care Med. 2010 Aug;38(8):1623-9
6. Conflicts in the ICU: perspectives of administrators and clinicians. Danjoux Meth N, Lawless B, Hawryluck L. . Intensive Care Med. 2009 Dec;35(12):2068-77.