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)