An 82-year-old man is admitted to the hospital after an out-of-hospital cardiac arrest. He was successfully resuscitated and intubated in the field by paramedics and transferred to the hospital's intensive care unit. On day 3 of hospitalization, he remains minimally responsive to most stimuli. The hospital has the patient's advance directive on file, which clearly states that the patient does not want life-sustaining treatment, including mechanical ventilation. The patient's wife agrees with the advance directive and wants to withdraw life support. The rest of the family, including a son and 2 daughters from a previous marriage, become very upset with her decision and strongly oppose the withdrawal of life support. They claim that their father's wife "never really cared for him and married him only for his money." They would like to continue mechanical ventilation to see if their father's condition improves. Despite multiple meetings with all family members in an attempt to reach a mutual decision, the patient's children and wife continue to disagree about management. Which of the following is the most appropriate next step in management of this patient?

Question

An 82-year-old man is admitted to the hospital after an out-of-hospital cardiac arrest.  He was successfully resuscitated and intubated in the field by paramedics and transferred to the hospital's intensive care unit.  On day 3 of hospitalization, he remains minimally responsive to most stimuli.  The hospital has the patient's advance directive on file, which clearly states that the patient does not want life-sustaining treatment, including mechanical ventilation.  The patient's wife agrees with the advance directive and wants to withdraw life support.  The rest of the family, including a son and 2 daughters from a previous marriage, become very upset with her decision and strongly oppose the withdrawal of life support.  They claim that their father's wife "never really cared for him and married him only for his money."  They would like to continue mechanical ventilation to see if their father's condition improves.  Despite multiple meetings with all family members in an attempt to reach a mutual decision, the patient's children and wife continue to disagree about management.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: The principle of patient autonomy requires that the physician respect the patient's decision to withhold or withdraw life-sustaining treatment. A competent adult patient may, via an advance directive, formulate and provide valid consent to withhold or withdraw life-supporting treatment in the event that any injury or illness renders that individual incapable of making such a decision. In this case, there is an advance directive clearly stating the patient's wishes; therefore, life support should be withdrawn. This patient's decision to not have mechanical ventilation, as outlined in the advanced directive, overrides the wishes of all family members. The physician should attempt to explain the patient's wishes to the children and help them come to terms with their father's decision. (Choices A and C) The use of courts or an ethics committee to resolve disputes regarding withdrawal of life support is necessary only when there is no advance directive. (Choice D) The wife's motives are irrelevant. The children should be informed that it is their father's wishes, as stated in his advance directive, that must be honored. (Choice E) Life support should be withdrawn because it is the patient's wish as documented in his advance directive, not because his wife is his next of kin. In cases in which there is no advance directive and the patient lacks decision-making capacity, the patient's spouse (not the children) would have priority in making a substituted judgment regarding what the patient would have wanted. Educational objective: Patient preference, as outlined in advance directives, should always prevail in the case of any family conflict regarding the withdrawal of life support. References: Advance directives: empowering patients at the end of life. (http://www.ncbi.nlm.nih.gov/pubmed/25286366) Advance care planning: a systematic review of randomised controlled trials conducted with older adults. (http://www.ncbi.nlm.nih.gov/pubmed/27451328)

An 82-Year-Old Man Is Admitted to the Hospital After an Out-Of-Hospital