Without Surrogates: Who Should Give Medical Permission if the Patient Can’t?
Picture this: An elderly man is brought to the hospital by the paramedics who police found living in a large cardboard box under a freeway overpass. The patient is unconscious and a workup shows that he suffered a head injury with some brain hemorrhage. There is also some damage to a foot which may represent early gangrene. Because he is not breathing adequately on his own, in the emergency room a tube was passed down into his trachea toward his lungs and he was put on the respirator for ventilation. He has no identification found in his clothing and there were no people in the area where he was found that admitted knowing him. It is too early for the doctors to know what will be the patient’s clinical outcome and when, if ever, he will be alert enough and capable of understanding his condition or treatment to have the capacity to make medical decisions about himself.
The doctors have performed some emergency procedures including inserting IV lines and inserting the endotracheal tube but they are concerned regarding who will give them permission to perform some more routine procedures, though having some risks, such as performing a tracheotomy (surgically opening a hole in the neck and trachea) to facilitate the ventilation process and to insert a tube through the abdomen into the stomach for feeding rather than continuing intravenous feeding. Further, if the patient is to survive, it may be necessary to amputate the gangrenous foot.
The question the doctors ask the ethics committee is who is going to give permission for them to perform the tracheotomy, insert the tube for longer term feeding and to authorize the necessary amputation of the slowly progressing gangrenous foot. For patients who are unable to make their own decisions and there is no individual, representing the patient, to give permission for the surgeries. there have been no legal guidelines regularly followed in the United States to answer their question. One possibility is to request from the courts the appointment of a legal guardian that would make such decisions. That guardian would make this unfamiliar patient one of many dozens of patient cases on that person’s workload. The guardian may not have time to visit and follow the patient closely enough to make judgments which should be in the best interest of that particular patient. There also may be delays in providing a decision. Other possibilities which have been considered is for the attending doctor simply to decide for the patient alone or as has been a common practice for two physicians to agree that the procedure is necessary and should be performed. There are some suggestions that hospital ethics committees or a hospital “surrogate” committee should take the responsibility for making decisions and giving permission for patients in their hospital who have no family or legal surrogates. In all of these examples, the possible conflict of interest issue is present, even in the case of the court appointed guardian who may find that keeping the patient alive longer despite clinical futility is of personal financial value.
This issue regarding who should make medical decisions for patients without capacity to make their own decisions but also without friends, family or surrogates who know them is the issue all ethics committees have worried over and have been trying to come to a answer that would represent the best,most just and efficient decision making for such a patient.
I think that the public should help the ethics committees by providing their views of the issue. As a chairperson of a hospital ethics committee, I ask for your help. ..Maurice.