Question of the Week # 24

•A 67-year-old woman has suffered a massive subarachnoid hemorrhage. The patient was well until three days prior when she had a sudden loss of consciousness. After emergent transport to the local hospital where her trachea was intubated and a CT scan disclosed a large grade 4 subarachnoid bleed, she was transferred to the intensive care unit. Over the past 72 hours her condition is unchanged. She in nonresponsive to deep painful stimulus, there is no dolls’ eye or gag reflex, and corneal blink reflex is absent. She has had no narcotics, analgesics, or paralytics. There is discord present within the family about whether to withdraw care. The husband desires care to be withdrawn whereas the children want to continue maximal supportive care. You explain that the most important determining factor in helping to direct future care is 

  A. the decision of a court appointed legal guardian • 

B. the decision of the medical and nursing team taking care of the patient • 

C. the husband’s wishes given that he is the health care proxy • 

 D. the opinion of the hospital ethics committee • 

E. the patient’s previously expressed wishes regarding life support if known

26 Responses

  1. e

  2. archer when will u post the answers?

  3. B . the decision of the medical and nursing team taking care of the patient •
    Subject is brain dead.

  4. i would like to know the answers for the questions…..when will u post them archer??

  5. e

  6. E

  7. e

  8. B

  9. eeeeeeeeeeeeee

  10. E

    please post the answer.

  11. EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE

  12. Answer is E.

    In these difficult situations where the patient is not able to make their own decisions and when there is disparate views among family members, the most important directing factor should be what the patient would have decided were they able to speak for themselves. Therefore, previously expressed views on what the patient would want if faced with a similar situation could prove invaluable in helping to direct care in the direction that the patient would have wanted. Court appointed legal guardians (choice A) are utilized when a patient has no family or has family members who are not competent to help make medical decisions on behalf of the incapacitated patient. If the patient has a clearly expressed view, this view would supercede any sentiments by the medical team (choice B), the husband (choice C), or a hospital ethics committee (choice D).

    • a ‘clearly expressed view’ required definition.
      Many hospitals WILL NOT accept a statement of ‘she said…..” They require previously submitted or legally signed directives. Next best thing is next of kin, husband.

  13. eee

  14. The answer of Dr. Red unfortunately may be incorrect, because the patient is brain dead. Whatever the discord among the patient’s family members, still the supportive measure should be withdrawn but there should be a discussion with the family, because this is a futile work. Suppose the family members discussed the issue among them and arrive to coordinated decision that they want the supportive measure to be continued. It is not acceptable to keep a brain dead on the supportive measures indefinitely. No one of the insurance company pay for supportive measures for a brain dead patient.

    • agredd with u dr ahmed

  15. Or suppose that the patient wishes are to keep the supportive at its maximum. There is no point of continuing a supportive care for a brain dead patient even if he expressed a wishes for continuing life support. In this case the decision is for the medical staff.

    • The question is not testing the concept of medical futility. And the question does not mention whether patient’s wished for continuing care further or DNR. Before you decide to proceed on basis of medical futility, you must look at what patient has in place – a living will or previously expressed wishes. If these wishes says “DNR”, your job becomes easy and you can proceed legally without bringing in the concept of “futility” . If by chance his wishes says to do “everything”, then you go to your next step and withdraw care based on “futility”.

  16. Clearly, the question gave the picture of brain death. Then I do not need to know if DNR present or not, because it will not affect my decision. I know exactly what principle you are explaining, but to answer MCQ question, we have to choose the best possible answer which, I think, is not the patient’s expressed wishes for this question. You may change the question to fit what do you want to explain. Thanks

    • Medical team can only propose to discontinue care based on “futility”. You can not go and withdraw life support immediately without discussing with the patient’s family or without satisfying the procedure involved in declaring a case futile . Because patient’s family always has an option to “obtain an ethics consult” or “to transfer to another facility”, you must give them those options – we are not dictators, we can refuse care based on futility grounds but we can not object if the family wants to take the patient to a different facility.

      Note this : “When the attending physician has documented these futility
      determinations in the patient’s medical record, and another attending physician,
      after examining the patient, has reached the same medical conclusions and
      similarly has documented this agreement in the patient’s medical record, the
      patient’s attending physician is under no obligation to initiate or to continue such care.
      When a decision has been made that the requested
      treatment or intervention is futile based on the above criteria and that
      determination has been confirmed by another physician with appropriate expertise
      who has no prior or present relationship with the patient, the patient or the
      patient’s representative(s) shall be so informed. If the patient or the patient’s
      representative(s) disagree with the decision to withdraw or not to initiate futile
      intervention, the patient/family/representative should be referred to the Ethics
      Committee and given the opportunity to secure the services of another physician.
      The family should be supported in their efforts to secure services of another
      physician, if that is their wish. ”

      So, the most helpful immediate factor that helps in deciding on the care is still Option E. Option B is a process not something that can be done by one physician – Option B also requires another physician NOT INVOLVED in direct care of patient to attest and agree with attending doctor that the care is futile

      • I have to disagree. The health care proxy or husband is the person to turn to for an answer. This assumes the document is in the patient record. No one else has the right to speak or make decisions for an incompetent patient unless it is through the court system. If I were health proxy for my spouse and the hospital followed a course of action determined by another family member or a staff nurse? unless I was not available this is not ethical or per standard.

      • This is helpful, I will have less of an impulse go with the futility idea, it’s clearly not that simple. Usually I’ve seen “discuss with the familty” in cases that appear futile.

  17. ^^^They are the experts for a reason.

  18. Guys! Dr Archer has shown how a lot of info in the question can distract judgement. Just read the question stem first. I bet everyone will instinctively think of ‘doctors call’ in this patient if he reads the whole question. But the examiners know that and wants to make it as real as possible and see how you/I/we will handle the situation. So what is the next step if this patient dies and there is commotion. You are standing there and there is commotion. The patient is not moving. The relatives can see that. They know what this means, you know what has happened but some of them are in denial, some are hoping that he will just open his eyes like in TV serial Grey’s anatomy. But at this stage most of them are confused. You think they will let you pull the plug? Then maybe one of them (the husband, gathers himself and raises the idea of ‘withdrawing life support’) and unwillingly produces more commotion. You think they will let you pull the plug now?
    If I was a relative, I will not let you touch my loved one with this thought right now. I will take him to a different hospital. Though I would expect you to do that shock thing I see on tv serial. You haven’t done that and u want to pull the plug? No way, I will doubt your medical competence in this matter if you go for pulling the plug. I will not let you do that. They don’t know about gag reflex or corneal reflex. I mean, I don’t know about gag reflex or corneal reflex.
    You have to explain something: you can start explaining gag reflex and corneal reflex. I bet you they will still not be convinced.
    So,
    What is the best option?
    You explain to them that the most important determinant factor to help in directing future care. So what do you say it is?
    Gag reflex?
    Doctor’s call? Not going to work, if I am a relative.
    Husband’s call? As far as I am concerned, he is not thinking straight right now. So ignore him.
    The court call? No way! As a relative I would get loan and fight u in court for years.

    Well who cares, I am the doctor, I pull the plug right? The problem is, The commotion will increase, you will have to call in security, there will be a scene, some of the violent relative may even think of hurting you personally later for making this call. It will become a personal issue and you will need a senior to intervene and moderate. Then most of the relatives will doubt your skills and you lose the game. This Question tests peoples skills, many doctors lack it and any doctor can pull the plug. But in reality will u let that happen to your relative in this situation? The doctor in charge has to do explaining, to convine everybody. So how will you do that? – just pull the plug?
    The idea is that u did not solve the issue here. You just joined in the commotion.
    But if you said, ‘the patient decides’, everyone will agree. The commotion subsides, now they will follow that the patient can not speak and the next of kin will be voted for by the family. They will all agree with his or her decision. Most importantly, you remain the commanding officer in charge of the ship and your senior will not have to intervene.
    Summary,
    Let them know the sequence, patient, then next of kin, then doctor or court. Managing a patient means you stay in charge. In this situation the only way to do that is to approach from a neutral point, the patients point. People’s skill, managerial skill, in medicine distinguishes a senior resident from a junior resident. If you pick option ‘ pull the plug’ I guarantee, a senior resident will have to take over this patient from you.
    Step 3 is about management skills. Agreed it sounds like MBA not MD. But the best doctors are the best managers.

  19. E

  20. The patient needs a brain death protocol. This is not a futility decision. Futility means that the patient is alive but we think the care is futile and will not lead to any quality of life. This patient based on the question stem has an exam that is so far consistent with brain death, but it needs a formal protocol to determine this. Patients who are determined to be brain dead are LEGALLY dead. There is no ethical dilemma there. Physicians are allowed to and should withdraw care for brain dead patients once diagnosis of brain death has been confirmed, regardless of what family members or patients themselves wanted in the past.

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