Want to Do Hospital Committee Ethics? (3): Case of Apparent Conflict of Interest
FACTS: The patient is a 72 year old man who was to be admitted to the hospital from a private nursing home to have a defective feeding tube replaced through the abdominal wall. The patient has been in a coma, but can breathe on his own, for the past 9 months after a head injury suffered in an auto accident. He has no family except for a brother, age 60, who is his designated Durable Power of Attorney for Health Care but who lives far away and who has visited the patient only on a couple of occasions. Other than this designation, there is no written expression of the patient’s personal desires. The only other relative is a male cousin who lives near by and has visited the patient several times each month. The brother has contacted the patient’s physician and requests that the feeding tube not be replaced and the patient allowed to die peacefully. He stated that he knew his brother would not like to remain in a comatose condition. The physician, with neurology consultation, has related to the brother that the patient may eventually recover to some degree. The cousin has contacted the doctor and informed him that the brother is known to be the beneficiary of the patient’s estate and questions the motives of the brother’s decision. The physician has taken the matter to his hospital’s ethics committee for help in resolution.
THE ISSUE: The ethics of termination of life support for this head injury patient and to what extent should the decisions of the legal surrogate be followed if conflict of interest is suspected.
QUESTION: Should the defective feeding tube not be replaced and patient allowed to die on the request of the legal surrogate? ..Maurice.
posted by Maurice Bernstein, M.D. @ 5:54:00 AM
1 comments
1 Comments:
There is insufficient information of the neurologic state of the pt. Since he may recover, to some degree, some waiting period should be considered. There is no necessity to rush. Nor is there any reason to fear replacing the tube, as doing so does not mean that the tube cannot be removed at a later time. The physician and family should be reasusured that this is not a moment of opportunity which forces an immediate decision. The pt. is not in a persistent - chronic- neurologic state - vegitative or otherwise. Albeit there is a durable power of attorney - health directive - it is unclear what the pt's wishes are.
(1)The EC should obtain an informed consent which would require the brother to have a detailed account and understanding of the Pt's progress and probability of recovery and quality of life.
(2) 4650 of the California Probate Code sets forth that (a)...an adult has the fundamental right to control the decisions relating to his or her own health care, including the decision to have life-sustaining treatment withheld or withdrawn; and (b)... In the interest of protecting individual autonomy, this prolongation of the process of dying for a person for whom continued health care does not improve the prognosis for recovery may violate patient dignity and cause unnecessary pain and suffering, while providing nothing medically necessary or beneficial to the person." Thus the EC would be within its power to withdraw the tube, EXCEPT, there is a controversy raised buy the cousin, who apparently knows the condition of the pt. 4650(c) holds that where there is controversy the court may be the appropriate way to have this matter decided.
(3) It would be safer for the EC to do so, and no apparent burden on the pt, save the possibility of improvment. This would provide the Pt with respect and dignity of allowing for a considered evaluation and decision. In the recent case of Wendland, the trial court ordered continued therapy before reconsidering wihdrawel of treatment. This would be a prudent recommendation for the ES to make. Both the brother and cousin should be advised of the need for court intervention. The hospital should bring the matter to the attention of the court for determination of withdrawing life sustaining treatment. The EC should not pass the buck back to the nuring home as the request to withdraw tretament occured at this hospital. In the mean time further neurolgic opinion can be sought.
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