* * Anonymous Doc

Wednesday, June 9, 2010

Ethical dilemma.

Patient has terminal illness. Not terribly alert-- can mumble his name, sometimes. Can open his eyes. Has a very clear advance directive-- no intervention, nothing life-prolonging.

He has a subdural hematoma. Without intervention, blood builds up, brain herniates, and he dies. Certainly a quicker death than his terminal illness. But advance directive is clear.

Daughter insists we need to ignore the advance directive, insert a drain into his head, keep the blood from accumulating, will prolong his life some undeterminable amount of time. Unclear if it really increases suffering, because he's suffering regardless, but certainly predisposes him to more infections, etc.

Dying regardless. Advance directive clear. Daughter insisting we ignore advance directive.

I knew this patient when he was alert, I treated him a few months ago for the terminal illness, we don't want to just let him die, but he's dying regardless of what we do.

So do we insert the drain, or do we honor the advance directive? On the one hand, what's the point of the advance directive if it's not going to be followed. On the other hand, his daughter is the health care proxy and she wants the procedure done.

Ethically, the right answer seems clear-- the advance directive is clear, the advance directive is the representation of the patient's wishes, we should listen to the patient. Practically, it is more difficult, because the daughter is a real person, who cares about her father, and wants us to help him. And is making it difficult for us not to help him.

Medically, it's the thing we would do if not for the advance directive. The daughter wasn't trying to force us to do something that we wouldn't do, from a purely medical standpoint. It's only the advance directive that changes the calculation.

So, what do we do?

(and while I think I know what's being done, based on what people were saying yesterday, I won't know for sure what they ended up doing until I'm back at work tonight)


  1. I could be wrong, but I think that the family's wishes only count if the patient wasn't clear about the situation in his advanced directive. If he truly said "No interventions" then let the hematoma stay. It is what is best for the patient according to the patient.

  2. Legally the patient has made his wishes clear, you follow the patient's wishes as they override the daughter's ability to make medical decisions for the patient. So the correct thing to do is to...

    ...call administration and get the legal team on board and make sure your butt is covered and fully documented.

  3. As a patient myself with a brain tumor who has taken tremendous effort to have a living will and directives, you must honor the patients wishes. Family members may be unable to say goodbye or be willing to accept reality, but this is what the patient wants. To do otherwise is only disrespectful to the patient.

  4. Actually, if the daughter wishes to override the advance directive, you have to follow her wishes. As far as I know, advance directives in any state can be revoked at any time by either the patient or the guardian. I'm not a lawyer, but I am a professional bioethicist (really).

  5. The purpose of legalizing advance directives is to make sure that the person's decision will be respected whether to continue or not with life sustaining treatments. Laws concerning advance directives varies from country to country. It is important to consult with a reputable law firm within your area regarding this ethical issue. My grandma is living in Ontario. Her doctor advised her that she needed to undergo a major surgical operation. Since she is 75, she does not wish to be resuscitated in case a problem will be encountered with the procedure. She consulted with an estate lawyer in Ottawa about her decisions. Grandma will be having her operation in a few weeks from now. We are all hopeful that everything turns out okay.