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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
59c* Triage - COVID 19
[C59:1] A patient with quadriplegia is admitted with COVID. The patient requires admission to the ICU, but the attending practitioner says that the quality of the patient’s life does not warrant aggressive treatment. The patient’s family disagrees. What should be done?
[C59:2]
- A. Do not admit the patient to the ICU because the practitioner has the authority to determine who gets admitted into the ICU and who does not.
- B. Do not admit the patient to the ICU because the quality of life is more important than quantity of life.
- C. Let the courts decide.
- D. Admit the patient to the ICU because the practitioner has the professional obligation to promote the quantity of life.
- E. Admit the patient to the ICU because the patient’s family has the decision-making authority.
- F. The practitioner needs to get informed consent from the patient.
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TAC: Think - Assess - Conclude
I. Think: What is the question?
[C59:3] Who has decisional authority?
II. Assess: Specify & Balance the four principles of bioethics
Patient: 1) Autonomy - Informed Consent
[C59:4] Competent adults with decisional capacity have the legal and moral authority to accept or reject treatment options through the process of informed consent. Being a person with quadriplegia does not mean that the patient also lacks decisional capacity. Therefore, what the practitioner feels about quantity and quality of life, and whether or not the patient’s family agrees with the practitioner, is legally and morally irrelevant. Rather the patient has the right to authorize or reject the relevant treatment options, not the practitioner or family members.
[C59:5] If the patient were to lack decisional capacity, and if the family were to be the patient’s surrogate medical decision-makers, then they would legally and morally be obliged to make treatment decisions for the patient using substituted judgment, that is, by using the patient’s reasonable goals, values, and priorities for making treatment decisions, not their own. If the patient’s reasonable goals, values, and priorities are not determinable, then the surrogates are to make medical decisions based on what would maximize the patient’s best interests.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[C59:6] The practitioner has the professional obligation of beneficence (do good) and the professional obligation of nonmaleficence (do no harm) to provide treatment(s) that the patient has determined to be in their best interests not the practitioner. If the patient lacks decisional capacity, then the family would have the medical decision-making authority as long as the family uses substituted judgment. If the patient’s reasonable goals, values, and priorities are indeterminable, then the family should make medical decisions based on what would most likely be the patient’s best interests from the patient’s perspective.
[C59:7]
Public Policy: 4) Justice
The patient has the legal right to authorize or reject legitimate treatment options.
[C59:8]
[C59:9] As a negative right, others have an obligation to not interfere in the patient’s treatment authorization, and as a positive right, others have an obligation to provide the authorized treatment options.
[C59:10]
III. Conclude: Nationally or Professionally True Answer
[C59:11] Practitioner should get informed consent from the patient, not the family members. The family would only have surrogate decision-making authority if the patient were not to have decisional capacity, and there were no oral or written directives, no living will, and no durable power of attorney specifying a specific proxy.
Answer Options: [C59:12]
(Choice A) Do not admit the patient to the ICU because the practitioner has the authority to determine who gets admitted into the ICU and who does not.
A is the wrong answer. It is not the practitioner who gives informed consent, nor is it the family, rather it is the patient who has the legal and moral right to provide informed consent.
(Choice B) Do not admit the patient to the ICU because the quality of life is more important than the quantity of life.
B is the wrong answer. Quantity and quality of life are determined by the patient, not by the practitioner or family. If the patient lacks decisional capacity then such values will need to be determined using the patient’s reasonable goals, values, and priorities, not the practitioner’s or families.
(Choice C) Let the courts decide.
C is the wrong answer. There is no reason for the courts to get involved as the patient already has the moral and legal authority for providing the informed consent authorization for accepting or rejecting legitimate non-futile treatment options.
(Choice D) Admit the patient to the ICU because the practitioner has the professional obligation always to promote the quantity of life.
D is the wrong answer. Only the patient has the moral and legal authority to make quantitative and qualitative assessments. Even if the patient lacked decisional authority, the practitioner and the family still would have no moral or legal authority to make quantitative vs. qualitative decisions as to what would maximize the patient’s best interests independent of the patient’s reasonable goals and values and priorities.
(Choice E) Admit the patient to the ICU because the patient’s family has the decision-making authority.
E is the wrong answer. Only the patient has the moral and legal authority to make quantitative and qualitative assessments. Even if the patient lacked decisional authority, the practitioner and the family still would have no moral or legal authority to make quantitative vs. qualitative decisions as to what would maximize the patient’s best interests independent of the patient’s reasonable goals and values and priorities.
(Choice F) The practitioner needs to get informed consent from the patient.
F is the correct answer. Only the patient has the moral and legal authority for informed consent for what treatment is authorized or not authorized. The family would only have surrogate decision-making authority if the patient were not to have decisional capacity, and there were no oral or written directives, no living will, and no durable power of attorney specifying a specific proxy.
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Civil Rights
Obligation of others to Not Interfere
Negative Right
Obligation of others toProvide something
Positive Right
Assessment
No ICU
ICU
Principles
X
X
Autonomy
Beneficence
X
X
Nonmaleficence
X
X
X
Justice
X
