Sick, Unconscious and Without Family, Friends or Surrogates--What's Next?
OK..here's the deal: You are in a hospital sick..you are unconscious..you need to have a surgical procedure done to attempt to make you better to some degree but you are unable to weigh the risks and benefits or to give the surgeon permission to operate..you are unconscious. In addition..you have been homeless..you have lived on the street..different streets..you have no friends..you have no relatives..you have no one to come to the hospital to visit you or talk to your surgeon. The surgeon wants to make you better..he or she needs to operate..but there is no one..not you or anyone else to give the surgeon permission. There is no law where the hospital is located which would instruct anyone what to do under these circumstances..Should the surgeon act as a family member or legal surrogate and make the decision for you? If you really were that patient..what do you think would be legal and ethical.. what would be the fairest act for that doctor to do for your benefit? Should the surgeon make the decision for you? And what if the decision to be made was not simply to operate to attempt to make you better but involved a decision to stop all life-supportive treatment because your condition was hopeless and you would never recover. Who should make that decision? You can't..you are unconscious and you have no one to speak for you. Got the picture?
By the way, this scenario is not at all rare. It can happen every day in some hospital. Most states in the U.S. have no laws which tell doctors what to do under these circumstance. Sure, the doctor and hospital can take the problem to the courts and have a judge decide or to have a legal guardian appointed. But this takes time and there may be no time. The guardian will not be available to respond for every single medical procedure nor will the guardian be free of conflict of interest or free of pressure from the judge when it comes to terminating life-support. So the doctors and hospitals have to make up their own guidelines. But my question is ..what would you want them to do if a patient comes in with no capacity to make decisions and no friends, family or surrogates to help with a medical decision? ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:34:00 AM
3 comments
3 Comments:
If that patient were myself, I would hope that the physician would take my full condition into account, and make a decision from that criteria, and none other.
Can the patient be saved through surgery, or some other invasive procedure? If so, I think that the physician should undertake the procedure.
Would extending the patient's life be an act of futility, only lengthening a time of agony, with no hope of recovery? Then he should do what he can to ensure the patient is not in any pain or discomfort, and let nature take her inevitable course.
I know that those are simplistic replies ... I'm aware that not being a physician, never having to make that sort of decision, almost necessarily makes it a single-dimensional issue for me. However, that depth of understanding is the same as it would be if I were to find myself in that position.
Save life - whenever possible. Life is precious.
Moof, there are two decision possibilites that physicians must make on patients who are unconscious or otherwise unable to give informed consent and have no surrogates, family or friends. One is to DO SOMETHING for the patient. There are three conditions for this decision: one is that the procedure or treatment is necessary but trivial, acceptable by everyone and clearly of benefit with virtually no significant risk (example, drawing blood to check a blood sugar). A doctor can order the test without a patient's permission, even a conscious patient. The second, is to performing a non-trival procedure or effective treatment but treatment with risks in a life and death emergency and the patient can't give informed consent. The physician can, after his or her own professional evaluation of the benefit vs risk, perform the procedure or order the treatment without informed consent. The final condition is performing a non-trivial procedure or ordering a medication with significant risks when the patient's condition is non-emergent. It is the latter condition which puts a decisional and perhaps legal burden on the physician.
The other possibility is that of the physician being faced with a decision, in a patient who cannot give informed consent, of deciding to DO NOTHING such as withholding any treatment or withholding a treatment that could be life-supporting. If a treatment was known to be clinically ineffective, not physiologic and not the standard of medical practice then whether the patient was conscious or not, such treatment need not be given and is usually not a burdensome decision. However, if the procedure or treatment would be essential to support further life in a patient with no hope of recovery or recovery of ability to express personal wishes, then for the physician to decide, based on the clinical prognosis and what an ordinary person might consider for themselves in this situation, is something few doctors would want to decide on their own.
Leaving critical decisions entirely up the one doctor in situations which are non-emergent, non-trivial but therapeutic or where the treatment could be life-supporting but considered futile due to the prognosis is ethically and perhaps legally wrong. Most doctors will want other physicians to support their decisions or support by an ethics committee. ..Maurice.
I agree with Moof above... save life whenever possible. All decisions should be made with that objective in mind and also avoiding prolonging agony in a case which will eventually lead to death.
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