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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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60. Withholding & Withdrawing Treatment
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Conscientious and careful medical practitioners assign disease causes to natural laws, while the best scientists go back to medicine for their first principles.
~ Aristotle
Unplugging Controversy
The Importance of Upholding Autonomy and Best Interests in Withholding and Withdrawing Medical Treatment
Dr. Jackson had always been a conscientious and careful medical practitioner, assigning disease causes to natural laws. He had been practicing medicine for over 30 years and had seen it all, or so he thought. However, nothing could have prepared him for the events that would soon unfold in his own practice.
One afternoon, Dr. Jackson received a call from the hospital where his patient, Mr. Smith, was being treated for a severe brain injury. The medical team at the hospital had been discussing the possibility of withdrawing life-sustaining treatment (LSMT) for Mr. Smith, as he had been in a vegetative state for over a month, with no hope of recovery. However, Mr. Smith’s wife, who was his surrogate decision-maker, was vehemently opposed to the idea and had threatened to sue the hospital if they proceeded with withdrawing LSMT.
Dr. Jackson knew that he had to act quickly, as he was Mr. Smith’s primary care physician and had a duty to ensure that his patient’s autonomy and best interests were being upheld. He scheduled an urgent meeting with Mr. Smith’s wife and their children, who were also involved in the decision-making process. Dr. Jackson explained to them the principle of autonomy and the patient’s right to withhold and withdraw from medical treatment, as well as the moral obligation of medical practitioners to pursue the patient’s best interests.
However, Mr. Smith’s wife was still convinced that her husband would recover, and that withdrawing LSMT would be equivalent to murder. The tension in the room was palpable, and it was clear that the family was not going to reach a consensus on their own. Dr. Jackson suggested that they seek an ethics consultation to help guide their decision-making process.
The ethics consultation brought together a group of experts in medical ethics, including a philosopher, a lawyer, and a social worker. They discussed the principle of autonomy, the patient’s best interests, and the surrogate decision-making process, with Mr. Smith’s wife and family.
Mr. Smith’s wife was still opposed to the idea, but the ethics consultation had provided the family with a clearer understanding of the situation and had helped them come to a consensus. Dr. Jackson felt relieved that he had been able to uphold his duty as a medical practitioner and ensure that his patient’s autonomy and best interests had been protected.
The events that had unfolded had been a sobering reminder to Dr. Jackson and his colleagues about the importance of upholding the principles of autonomy, beneficence, nonmaleficence, and justice when it comes to withholding and withdrawing medical treatment. They knew that they would never forget this experience and would continue to prioritize their patients’ well-being above all else.
Abstract
The right of patients to withhold and withdraw from medical treatment is based on the principle of autonomy and the moral obligation of medical practitioners to pursue the patient’s best interests and “first do no harm.” The patient’s autonomy is protected through informed consent, living wills, durable power of attorney for health care, and surrogate decision-making by next of kin. In the event of disagreement among surrogates, an ethics consultation can be sought to reach a consensus. Legally, in the US, common law recognizes the patient’s right to withhold and withdraw from treatment, but there may be controversy over the evidence accepted as proof. The right to withheld and withdraw from medical treatment is essential to maintaining the patient’s autonomy, interests, and well-being, and practitioners should support patients and surrogates in these decisions.
**
Think
[60:1] Professionally, legally, and morally, there is no difference between refusing a medical treatment provided and withdrawing from a medical treatment already begun. Making a false distinction between the two increases the patient’s fear that once a treatment is started, the treatment can never be stopped, no matter how harmful to the patient or against the patient’s later judgment.
[60:2] Patient fear resulted in the mantra of the medical profession: “Primum non nocere,” Latin for “first do no harm.” The closest approximation of the mantra is from the Epidemics in the Hippocratic Corpus:
ἀσκέειν, περὶ τὰ νουσήματα, δύο, ὠφελέειν, ἢ μὴ βλάπτειν
[The medical practitioner must] … have two special objects in view concerning disease, namely, to do good or to do no harm (book 1, sect.11)
The Hippocratic Oath states:
I will keep them from harm and injustice
[60:3] The patient’s right to withhold and to withdraw from treatment is a recognition of the patient’s autonomous right to be in control of what is done to their body and a foundational professional obligation of the practitioner: first do no harm.
Assess
Patient: 1) Autonomy
[60:4] Based on the individual moral principle of autonomy, all competent adults with decisional capacity have the right to exercise informed consent, meaning the informed determination of what treatments they are to receive, withhold, or withdraw. There is no professional, legal, or moral distinction between withholding and withdrawing medical treatment, even though there may be an emotional or experiential distinction. The patient always has the right to stop a treatment that has been started. This autonomous moral right to withdraw treatment provides the patient the freedom and opportunity to experiment and try out various treatment options knowing that, at any time and for any reason, the patient can exercise their autonomous authority and withdraw from the treatment, regardless, and independently of other people’s opinions, beliefs, and objections.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[60:5] Professionally, the medical practitioner has the moral obligation to pursue the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. If the patient loses their decisional capacity, then in hierarchical order, the practitioner should use:
- 1. the most recent oral or written documents indicating patient consent for the withholding or withdrawing treatment,
- 2. a living will that expresses what treatment options the patient would wish to have or not have,
- 3. a durable power of attorney for health care, which indicates who is to make medical decisions for the patient, (Durable meaning that the proxy’s authority to make medical decisions becomes effective once the patient loses decisional capacity or consciousness.)
- 4. next of kin, which may vary slightly from state to state, but in general, the order of surrogate authority is the patient’s:
1) guardian,
2) spouse,
3) adult offspring(s),
4) either parent,
5) any adult sibling,
6) any adult grandchild,
7) close friend,
8) guardian of the estate,
9) temporary custodian.
[60:6] The assumption is that the surrogate decision-making list is in the hierarchical order of which individual(s) would have the best knowledge of the patient’s reasonable goals, values, and priorities, so that the surrogate(s), using substituted judgment, can make medical decisions the way the patient would have. This hierarchical structure of authority exemplifies the high degree of importance of individual patient autonomy (informed consent) by oral or written document, to a living will, to a patient’s proxy whose goal is to make medical decisions using substituted judgment, meaning using the patient’s reasonable goals, values, and priorities when making medical decisions. This high degree of patient-centered decision-making is believed to maximize the patient’s best interests.
[60:7] If surrogates are unable to determine whether or not the patient would wish to withdraw life-sustaining medical treatment (LSMT), and there is disagreement as to whether or not that would be in the patient's best interests, then that would be a time in which an “ethics consultation” would help bring the surrogates into consensus.
Public Policy: 4) Justice
[60:8] In the United States, common law has legally established that patients have the autonomous right to withhold and to withdraw from medical treatment. Although there is state controversy about what evidence is accepted as proof of a patient’s desire to withdraw life-sustaining medical treatment (LSMT) after losing decisional capacity, there is no legal controversy that then the surrogate has the legal right to withhold and withdraw medical treatment.
Conclude
[60:9] Patient’s have the legal, professional, and moral right to withhold and withdraw medical treatment. However, issues arise when surrogates cannot agree on whether or not to withdraw life-sustaining medical treatment (LSMT) for a patient when the patient’s desires are not determinable. In such situations, the practitioner should encourage surrogate discussion. If such surrogate discussions fail to promote a consensus, then bringing in a third party “ethics consultation” will assist the surrogates toward a decisional consensus.
[60:10} In summary, patients have the right to withhold and withdraw from medical treatment based on the principle of autonomy and the moral obligation of medical practitioners to pursue the patient’s best interests. The patient’s autonomy is protected through informed consent, living wills, durable power of attorney for health care, and surrogate decision-making. Legally, in the US, common law recognizes the patient’s right to withhold and withdraw from treatment. The practitioner’s moral obligation is to first do no harm and to pursue the patient’s best interests. When surrogates cannot agree on whether or not to withdraw life-sustaining medical treatment for a patient when the patient’s desires are not determinable, an ethics consultation can be sought to help guide the decision-making process.
**
CORRECT! 🙂
[60:2] Patient fear resulted in the mantra of the medical profession: “Primum non nocere,” Latin for “first do no harm.” The closest approximation of the mantra is from the Epidemics in the Hippocratic Corpus: ἀσκέειν, περὶ τὰ νουσήματα, δύο, ὠφελέειν, ἢ μὴ βλάπτειν
[The practitioner must] … have two special objects in view concerning disease, namely, to do good or to do no harm (book 1, sect.11)
The Hippocratic Oath states:
I will keep them from harm and injustice
60. Review Questions
1. The mantra of the medical profession: “Primum non nocere,” Latin for “first do no harm.”
2. There is no professional, legal, or moral distinction between withholding and withdrawing medical treatment, even though there may be an emotional or experiential distinction.
3. This autonomous moral right to withdraw treatment provides the patient the freedom and opportunity to experiment and try out various treatment options knowing that at any time and for any reason, the patient can exercise their autonomous authority and withdraw from the treatment.
4. The assumption is that the surrogate decision-making list is in the hierarchical order of which individual(s) would have the best knowledge of the patient’s reasonable goals, values, and priorities, so that the surrogate(s), using substituted judgment, can make medical decisions the way the patient would have.
5. If surrogates are unable to determine whether or not the patient would wish to withdraw life-sustaining medical treatment (LSMT), and there is disagreement as to whether or not that would be in the patient's best interests, then that would be a time in which an “ethics consultation” would help bring the surrogates into consensus.
6. [60:8] After the patient loses decisional capacity, there are various legal controversies as to whether or not a surrogate has the legal right to withhold and withdraw life-sustaining medical treatment (LSMT).
**
Wrong 😕
[60:2] Patient fear resulted in the mantra of the medical profession: “Primum non nocere,” Latin for “first do no harm.” The closest approximation of the mantra is from the Epidemics in the Hippocratic Corpus: ἀσκέειν, περὶ τὰ νουσήματα, δύο, ὠφελέειν, ἢ μὴ βλάπτειν
[The practitioner must] … have two special objects in view concerning disease, namely, to do good or to do no harm (book 1, sect.11)
The Hippocratic Oath states:
I will keep them from harm and injustice
CORRECT! 🙂
[60:4] Based on the individual moral principle of autonomy, all competent adults with decisional capacity have the right to exercise informed consent, meaning the informed determination of what treatments they are to receive, withhold, or withdraw. There is no professional, legal, or moral distinction between withholding and withdrawing medical treatment, even though there may be an emotional or experiential distinction. The patient always has the right to stop a treatment that has been started. This autonomous moral right to withdraw treatment provides the patient the freedom and opportunity to experiment and try out various treatment options knowing that at any time and for any reason, the patient can exercise their autonomous authority and withdraw from the treatment, regardless, and independently of other people’s opinions, beliefs, and objections.
CORRECT! 🙂
[60:4] Based on the individual moral principle of autonomy, all competent adults with decisional capacity have the right to exercise informed consent, meaning the informed determination of what treatments they are to receive, withhold, or withdraw. There is no professional, legal, or moral distinction between withholding and withdrawing medical treatment, even though there may be an emotional or experiential distinction. The patient always has the right to stop a treatment that has been started. This autonomous moral right to withdraw treatment provides the patient the freedom and opportunity to experiment and try out various treatment options knowing that at any time and for any reason, the patient can exercise their autonomous authority and withdraw from the treatment, regardless, and independently of other people’s opinions, beliefs, and objections.
Wrong 😕
[60:4] Based on the individual moral principle of autonomy, all competent adults with decisional capacity have the right to exercise informed consent, meaning the informed determination of what treatments they are to receive, withhold, or withdraw. There is no professional, legal, or moral distinction between withholding and withdrawing medical treatment, even though there may be an emotional or experiential distinction. The patient always has the right to stop a treatment that has been started. This autonomous moral right to withdraw treatment provides the patient the freedom and opportunity to experiment and try out various treatment options knowing that at any time and for any reason, the patient can exercise their autonomous authority and withdraw from the treatment, regardless, and independently of other people’s opinions, beliefs, and objections.
Wrong 😕
[60:6] The assumption is that the surrogate decision-making list is in the hierarchical order of which individual(s) would have the best knowledge of the patient’s reasonable goals, values, and priorities, so that the surrogate(s), using substituted judgment, can make medical decisions the way the patient would have. This hierarchical structure of authority exemplifies the high degree of importance of individual patient autonomy (informed consent) by oral or written document, to a living will, to a patient’s proxy whose goal is to make medical decisions using substituted judgment, meaning using the patient’s reasonable goals, values, and priorities when making medical decisions. This high degree of patient-centered decision-making is believed to maximize the patient’s best interests.
CORRECT! 🙂
[60:6] The assumption is that the surrogate decision-making list is in the hierarchical order of which individual(s) would have the best knowledge of the patient’s reasonable goals, values, and priorities, so that the surrogate(s), using substituted judgment, can make medical decisions the way the patient would have. This hierarchical structure of authority exemplifies the high degree of importance of individual patient autonomy (informed consent) by oral or written document, to a living will, to a patient’s proxy whose goal is to make medical decisions using substituted judgment, meaning using the patient’s reasonable goals, values, and priorities when making medical decisions. This high degree of patient-centered decision-making is believed to maximize the patient’s best interests.
CORRECT! 🙂
[60:7] If surrogates are unable to determine whether or not the patient would wish to withdraw life-sustaining medical treatment (LSMT), and there is disagreement as to whether or not that would be in the patient's best interests, then that would be a time in which an “ethics consultation” would help bring the surrogates into consensus.
Wrong 😕
[60:7] If surrogates are unable to determine whether or not the patient would wish to withdraw life-sustaining medical treatment (LSMT), and there is disagreement as to whether or not that would be in the patient's best interests, then that would be a time in which an “ethics consultation” would help bring the surrogates into consensus.
Wrong 😕
[60:8] In the United States, common law has legally established that patients have the autonomous right to withhold and to withdraw medical treatment. Although there is state controversy about what evidence is accepted as proof of a patient’s desire to withdraw life-sustaining medical treatment (LSMT) after losing decisional capacity, there is no legal controversy that the surrogate has the legal right to withhold and withdraw medical treatment.
CORRECT! 🙂
[60:8] In the United States, common law has legally established that patients have the autonomous right to withhold and to withdraw medical treatment. Although there is state controversy about what evidence is accepted as proof of a patient’s desire to withdraw life-sustaining medical treatment (LSMT) after losing decisional capacity, there is no legal controversy that the surrogate has the legal right to withhold and withdraw medical treatment.
60. Clinical Vignettes
1. Ms. Maria Roberts is a 50-year-old accountant who has been diagnosed with early-onset Alzheimer's disease. She has been living with her husband and children, but her condition has worsened, and she has been admitted to the hospital due to complications from the disease. Ms. Roberts has lost decisional capacity, and her husband has been appointed as her surrogate decision-maker. The medical team has recommended that Ms. Roberts be placed on a ventilator due to respiratory failure, but her husband is conflicted about what decision to make. Ms. Roberts's advance directive did not include any instructions about life-sustaining treatment, and her husband is unsure whether to proceed with the ventilation or to withhold the treatment. What ethical principle is at stake in this case?
2. Ms. Mia Garcia is a 72-year-old retired teacher who has been diagnosed with terminal cancer. She has been admitted to the hospital with severe pain and difficulty breathing. Ms. Garcia is still able to communicate and has decisional capacity. She has expressed to her medical team that she does not want any further medical interventions and prefers to focus on palliative care to manage her symptoms. Ms. Garcia has designated her daughter, Maria, as her healthcare proxy in case she loses decisional capacity. However, Maria disagrees with her mother's decision and wants the medical team to do everything possible to prolong her life. What ethical principle is at play in this situation?
3. Ms. Susan Jenkins is a 75-year-old retired teacher who was recently diagnosed with advanced ovarian cancer. She has been receiving chemotherapy for several months, but her cancer has continued to progress. Ms. Jenkins has now lost decisional capacity and her husband has been appointed as her surrogate decision-maker. The medical team is recommending a new treatment option that could potentially extend Ms. Jenkins's life, but also carries significant risks and could decrease her quality of life.
4. Ms. Sophia Baker is a 78-year-old woman with a history of heart disease and dementia. She has been living in a nursing home for the past year and has recently been admitted to the hospital with pneumonia. While in the hospital, she experiences respiratory failure and requires mechanical ventilation. Ms. Baker no longer has decisional capacity. The medical team informs her daughter, who is her designated surrogate, that she may require a tracheostomy to continue the mechanical ventilation for an extended period of time. The daughter is hesitant to consent to the tracheostomy because she knows her mother would not have wanted to be on prolonged mechanical ventilation. However, she is also hesitant to withdraw life-sustaining treatment as she feels guilty and wants to do everything possible to keep her mother alive. The daughter asks the medical team to provide guidance on what the best course of action is.
5. Mr. Michael Ward is a 68-year-old man with advanced Parkinson's disease. He has been living in a nursing home for the past year and is frequently admitted to the hospital for treatment of infections. He has recently been admitted to the hospital with pneumonia and is having difficulty breathing. While in the hospital, he experiences respiratory failure and requires mechanical ventilation. Mr. Ward has decisional capacity and expresses to the medical team that he does not want to be on prolonged mechanical ventilation. However, his daughter, who is his designated surrogate, insists that he should receive all available treatment options to prolong his life, regardless of his wishes. What is the professional obligation of the medical team?
CORRECT! 🙂
Explanation: The ethical principle at stake in this case is beneficence [60:5]. Ms. Roberts's husband, as her surrogate decision-maker, has the responsibility to make decisions that are in her best interests and that align with her values and goals. If Ms. Roberts had previously expressed her wishes about medical treatment, then her husband should follow those wishes to the best of his ability [60:5]. If her wishes are not known, then her husband should make decisions that are in her best interests, based on the medical team's recommendations and other relevant information [60:5]. In this case, the medical team has recommended placing Ms. Roberts on a ventilator due to respiratory failure, and her husband must weigh the potential benefits of the treatment against the potential risks and harms [60:5]. While the medical team can provide guidance and recommendations, the final decision should be made by Ms. Roberts's surrogate decision-maker, and it should be based on what is in her best interests [60:5]. While autonomy is not directly at stake in this case since Ms. Roberts has lost decisional capacity, it is still an important consideration, as Ms. Roberts's husband should make decisions that align with her values and goals and that respect her autonomy as much as possible [60:1]. Nonmaleficence and justice are also relevant considerations in this case, but the primary ethical principle at stake is beneficence, as Ms. Roberts's husband must make a decision that is in her best interests [60:5].
Wrong 😕
Explanation: The ethical principle at stake in this case is beneficence [60:5]. Ms. Roberts's husband, as her surrogate decision-maker, has the responsibility to make decisions that are in her best interests and that align with her values and goals. If Ms. Roberts had previously expressed her wishes about medical treatment, then her husband should follow those wishes to the best of his ability [60:5]. If her wishes are not known, then her husband should make decisions that are in her best interests, based on the medical team's recommendations and other relevant information [60:5]. In this case, the medical team has recommended placing Ms. Roberts on a ventilator due to respiratory failure, and her husband must weigh the potential benefits of the treatment against the potential risks and harms [60:5]. While the medical team can provide guidance and recommendations, the final decision should be made by Ms. Roberts's surrogate decision-maker, and it should be based on what is in her best interests [60:5]. While autonomy is not directly at stake in this case since Ms. Roberts has lost decisional capacity, it is still an important consideration, as Ms. Roberts's husband should make decisions that align with her values and goals and that respect her autonomy as much as possible [60:1]. Nonmaleficence and justice are also relevant considerations in this case, but the primary ethical principle at stake is beneficence, as Ms. Roberts's husband must make a decision that is in her best interests [60:5].
Wrong 😕
[60:4] Based on the individual moral principle of autonomy, all competent adults with decisional capacity have the right to exercise informed consent, meaning the informed determination of what treatments they are to receive, withhold, or withdraw. There is no professional, legal, or moral distinction between withholding and withdrawing medical treatment, even though there may be an emotional or experiential distinction. The patient always has the right to stop a treatment that has been started. This autonomous moral right to withdraw treatment provides the patient the freedom and opportunity to experiment and try out various treatment options knowing that at any time and for any reason, the patient can exercise their autonomous authority and withdraw from the treatment, regardless, and independently of other people’s opinions, beliefs, and objections.
CORRECT! 🙂
Explanation: Ms. Garcia has the right to make her own medical decisions based on her values and preferences as long as she has decisional capacity [60:4]. Her daughter is struggling with a decision that is in line with her mother's previously expressed wishes while dealing with her own emotions [60:5]. The medical team should support Ms. Garcia's autonomy and work with her daughter to address any concerns or questions she may have [60:4]. In situations where surrogates are unable to determine what the patient would wish for, and there is disagreement about what would be in the patient's best interests, an ethics consultation can help reach a consensus [60:7]. It is important for the medical team to respect Ms. Garcia's autonomy and support her in her decision to focus on palliative care, while also addressing the concerns of her daughter [60:4].
Wrong 😕
Explanation: Ms. Garcia has the right to make her own medical decisions based on her values and preferences as long as she has decisional capacity [60:4]. Her daughter is struggling with a decision that is in line with her mother's previously expressed wishes while dealing with her own emotions [60:5]. The medical team should support Ms. Garcia's autonomy and work with her daughter to address any concerns or questions she may have [60:4]. In situations where surrogates are unable to determine what the patient would wish for, and there is disagreement about what would be in the patient's best interests, an ethics consultation can help reach a consensus [60:7]. It is important for the medical team to respect Ms. Garcia's autonomy and support her in her decision to focus on palliative care, while also addressing the concerns of her daughter [60:4].
CORRECT! 🙂
Explanation: The medical team should discuss the risks and benefits of the new treatment option with Ms. Jenkins's husband and make a joint decision based on what is in Ms. Jenkins's best interests [60:5]. While the medical team has a duty to pursue treatment that may benefit the patient's health [60:3], they must also consider the patient's well-being and quality of life. In this case, since Ms. Jenkins has lost decisional capacity, her husband has been appointed as her surrogate decision-maker [60:5]. However, the medical team should still involve him in a discussion of the risks and benefits of the treatment option and make a joint decision based on what is in Ms. Jenkins's best interests [60:6]. This approach honors the principles of patient autonomy [60:4] and beneficence, while also ensuring that the patient's best interests are prioritized.
Wrong 😕
Explanation: The medical team should discuss the risks and benefits of the new treatment option with Ms. Jenkins's husband and make a joint decision based on what is in Ms. Jenkins's best interests [60:5]. While the medical team has a duty to pursue treatment that may benefit the patient's health [60:3], they must also consider the patient's well-being and quality of life. In this case, since Ms. Jenkins has lost decisional capacity, her husband has been appointed as her surrogate decision-maker [60:5]. However, the medical team should still involve him in a discussion of the risks and benefits of the treatment option and make a joint decision based on what is in Ms. Jenkins's best interests [60:6]. This approach honors the principles of patient autonomy [60:4] and beneficence, while also ensuring that the patient's best interests are prioritized.
CORRECT! 🙂
Explanation: The daughter is in a difficult position, as she wants to honor her mother's wishes but is also struggling with the guilt of potentially withdrawing life-sustaining treatment [60:9]. The medical team should seek an ethics consultation to help the daughter make a decision [60:7]. An ethics consultation can help provide guidance on how to honor the patient's autonomy while also taking into consideration the surrogate's emotional and psychological state [60:7]. It is important to remember that the surrogate's role is to make decisions based on what the patient would have wanted, not what they personally want [60:4]. The medical team should support the surrogate in making an informed decision that aligns with the patient's values and beliefs [60:5].
Wrong 😕
Explanation: The daughter is in a difficult position, as she wants to honor her mother's wishes but is also struggling with the guilt of potentially withdrawing life-sustaining treatment [60:9]. The medical team should seek an ethics consultation to help the daughter make a decision [60:7]. An ethics consultation can help provide guidance on how to honor the patient's autonomy while also taking into consideration the surrogate's emotional and psychological state [60:7]. It is important to remember that the surrogate's role is to make decisions based on what the patient would have wanted, not what they personally want [60:4]. The medical team should support the surrogate in making an informed decision that aligns with the patient's values and beliefs [60:5].
CORRECT! 🙂
Explanation: Mr. Ward has decisional capacity and has expressed his wishes regarding his medical care [60:4]. The medical team should respect his autonomy and not provide prolonged mechanical ventilation, regardless of the surrogate's wishes [60:8]. It is important to remember that the surrogate's role is to make decisions based on what the patient would have wanted, not what they personally want [60:4]. The medical team should support the surrogate in understanding the patient's wishes and provide education on the benefits of honoring the patient's autonomy [60:5]. If there is a conflict between the patient's wishes and the surrogate's wishes, seeking an ethics consultation may be helpful in resolving the conflict and finding a solution that aligns with the patient's values and beliefs [60:7].
Wrong 😕
Explanation: Mr. Ward has decisional capacity and has expressed his wishes regarding his medical care [60:4]. The medical team should respect his autonomy and not provide prolonged mechanical ventilation, regardless of the surrogate's wishes [60:8]. It is important to remember that the surrogate's role is to make decisions based on what the patient would have wanted, not what they personally want [60:4]. The medical team should support the surrogate in understanding the patient's wishes and provide education on the benefits of honoring the patient's autonomy [60:5]. If there is a conflict between the patient's wishes and the surrogate's wishes, seeking an ethics consultation may be helpful in resolving the conflict and finding a solution that aligns with the patient's values and beliefs [60:7].
**
60. Reflection Vignettes
1. Dr. Emma Lopez, a 50-year-old critical care physician, admits a patient named John Smith, who is 70 years old, to the intensive care unit (ICU) due to multiple organ failure from sepsis. John is alert and oriented with decisional capacity and tells Dr. Lopez that he no longer wishes to undergo any aggressive LSMT, including mechanical ventilation or vasopressors. John explains that his quality of life is poor, and he wishes to die peacefully. Dr. Lopez discusses John's decision with him, explaining that it may hasten his death, and offers supportive measures like hospice and palliative care. She also ensures that his decision is informed, voluntary, and without coercion before honoring his wishes.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Ms. Evelyn Watson is a 65-year-old retired teacher who is now in the intensive care unit (ICU) with a severe case of pneumonia. Ms. Watson has three siblings who are making medical decisions for her. Two siblings, Mr. Michael Johnson and Ms. Patricia Brown, believe that their sister's quality of life is so poor that all life-sustaining medical treatment (LSMT) ought to be forgone. Mr. Johnson and Ms. Brown are concerned that their sister's suffering is unbearable and believe that continuing aggressive treatment would be futile. However, the third sibling, Mr. Robert Watson, is adamantly against such a decision. Mr. Watson believes that his sister would want all possible medical interventions, no matter what the outcome may be. The family is in disagreement about what medical decisions to make, and the attending practitioner must navigate this complicated situation while upholding ethical principles and the patient's wishes.
This is a classic example of how an ethics consult can help because there is a disagreement among the patient's family members regarding the best course of action for the patient's medical care. An ethics consult can provide a neutral and impartial perspective to help resolve the conflict and ensure that the patient's wishes and best interests are respected. An ethics consult can also provide guidance on how to approach the decision-making process, help clarify any legal or ethical issues involved, and facilitate communication between the different parties involved. Additionally, an ethics consult can provide support to the healthcare team in navigating complex ethical dilemmas and help ensure that the patient receives compassionate and appropriate care.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
60c*
Jehovah Witness
An adult parent and their 13-year-old child are presented to the emergency department (ED) unconscious and in critical condition. Death is imminent unless they both get blood, but there is time to get a surrogate consent who is present. There is no living will or durable power of attorney on record. The patient’s spouse, who is also the other biological parent of the child, informs the ED practitioner that both of the patients are Jehovah’s Witnesses and that it is against their religion to receive any blood and therefore requests that no blood be given to both the spouse and child. The spouse also said they had numerous discussions about such a situation occurring, and not getting blood was what they wanted. Both patients are also wearing No Blood medical alert wristbands. What should the practitioner do?
- A. Do as the surrogate dictates and do not give blood to either patient.
- B. Override the surrogate and give blood to both patients.
- C. Call for an Ethics Consult.
- D. Get a court order to give blood to both patients.
- E. Give blood to the child but not to the parent.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
60d*
False Beliefs
[D60:1]
An adult patient with schizophrenia is evaluated in the emergency department for acute rectal bleeding. A colonoscopy is recommended to diagnose and treat the hemorrhage. The patient refuses because they think that the procedure will give them HIV. What should be done?
[D60:2]
- A. Do not provide treatment until the patient understands that treatment will not result in HIV.
- B. Immediately call for a psychological evaluation to override the patient’s false belief.
- C. Call for an ethics consultation.
- D. Provide an alternative treatment option, even if it is not the accepted standard treatment.
- E. Discharge the patient.
- F. Provide emergency treatment that meets the best practice standard.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
