A 68-year-old man is brought to the hospital due to 2 days of progressive shortness of breath and cough. He has a history of severe chronic obstructive pulmonary disease and has had multiple recent exacerbations and several hospitalizations over the past year. During his last hospitalization, he had acute respiratory failure requiring endotracheal intubation. This prompted the patient to make a living will specifying that he does not want any resuscitative measures or invasive therapies in the event of a life-threatening emergency. On examination, he is lethargic and arousable only to noxious physical stimuli. His temperature is 37.2 C (99 F), blood pressure is 132/70 mm Hg, pulse is 102/min, and respirations are 32/min. Examination reveals diffusely decreased breath sounds, bilateral expiratory wheezes, and labored breathing. It is determined that he lacks decision-making capacity. His daughter says, "I have been taking care of my father for many years and I know him better than anyone. He would not want any aggressive measures. Please just make him comfortable." However, the patient's wife demands that everything be done to save her husband's life, including intubation if necessary. She insists that she knows what her husband would have wanted and threatens to file a lawsuit. Which of the following interventions is the most appropriate next step?

Question

A 68-year-old man is brought to the hospital due to 2 days of progressive shortness of breath and cough.  He has a history of severe chronic obstructive pulmonary disease and has had multiple recent exacerbations and several hospitalizations over the past year.  During his last hospitalization, he had acute respiratory failure requiring endotracheal intubation.  This prompted the patient to make a living will specifying that he does not want any resuscitative measures or invasive therapies in the event of a life-threatening emergency.  On examination, he is lethargic and arousable only to noxious physical stimuli.  His temperature is 37.2 C (99 F), blood pressure is 132/70 mm Hg, pulse is 102/min, and respirations are 32/min.  Examination reveals diffusely decreased breath sounds, bilateral expiratory wheezes, and labored breathing.  It is determined that he lacks decision-making capacity.  His daughter says, "I have been taking care of my father for many years and I know him better than anyone.  He would not want any aggressive measures.  Please just make him comfortable."  However, the patient's wife demands that everything be done to save her husband's life, including intubation if necessary.  She insists that she knows what her husband would have wanted and threatens to file a lawsuit.  Which of the following interventions is the most appropriate next step?

Quizplus · Accepted Answer

A living will (advanced directive) specifies a patient's wishes for health care in advance of losing the ability to communicate or of becoming incapable of making his or her own decisions. In this case, the patient is incapacitated and his family members strongly disagree on the best course of action; both claim to have a better understanding of what the patient would have wanted in the current situation. However, the physician's responsibility is to the patient, and ethically the physician must adhere to the patient's wishes as outlined in the living will. The living will protects the patient's autonomy and overrules the wishes of any family members. (Choices A, B, and C) Initiating a family meeting would be the first step if the family members disagreed about the course of action and there was no living will and/or no designated health care proxy in place. Referral to the hospital ethics committee or the courts for a judgment would become necessary if no consensus was achieved. (Choice D) Proceeding with CPR or intubation would violate the patient's wishes as expressed in his living will. Educational objective: A living will communicates the patient's own wishes if he or she becomes incapacitated, and it overrules the wishes of the family. References: Efficacy of advance care planning: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24598477)

A 68-Year-Old Man Is Brought to the Hospital Due to 2