A 74-year-old woman is brought to the emergency department by ambulance. She is accompanied by a friend, who found the patient confused and disoriented lying on the floor in her apartment. The patient is widowed and lives with her adult daughter. She was diagnosed with aplastic anemia a year ago. Her condition has responded poorly to immunosuppressive therapy and has required multiple blood transfusions. The patient is febrile, disoriented, and unable to respond to questions. Complete blood count shows severe pancytopenia. The patient has an advance directive, signed 9 months ago, in which she designated the friend as her health care proxy. The friend tells the physician that the patient did not want to undergo any further blood transfusions. The patient's daughter arrives and adamantly insists that the patient receive a blood transfusion, saying, "I discussed it with my mother a few weeks ago, and we decided that she should have everything done to prolong her life." Which of the following is the most appropriate next step in patient care?

Question

A 74-year-old woman is brought to the emergency department by ambulance.  She is accompanied by a friend, who found the patient confused and disoriented lying on the floor in her apartment.  The patient is widowed and lives with her adult daughter.  She was diagnosed with aplastic anemia a year ago.  Her condition has responded poorly to immunosuppressive therapy and has required multiple blood transfusions.  The patient is febrile, disoriented, and unable to respond to questions.  Complete blood count shows severe pancytopenia.  The patient has an advance directive, signed 9 months ago, in which she designated the friend as her health care proxy.  The friend tells the physician that the patient did not want to undergo any further blood transfusions.  The patient's daughter arrives and adamantly insists that the patient receive a blood transfusion, saying, "I discussed it with my mother a few weeks ago, and we decided that she should have everything done to prolong her life."  Which of the following is the most appropriate next step in patient care?

Quizplus · Accepted Answer

11ec160b_3651_9427_9249_cf59c33ea14f_MD0001_00 A health care proxy (eg, durable power of attorney for health care) is a surrogate decision-maker who has been designated by a patient and is legally enabled to make health care decisions on that patient's behalf. A health care proxy is obligated to make decisions in accordance with what he or she believes the patient would have wanted (ie, substituted judgment) and the patient's best interest. As with all forms of advance directive, a health care proxy must be designated when the patient is competent and is used only when the patient is presently unable to make health care decisions. A designated health care proxy takes legal priority over all other decision-makers, regardless of family relationship. In this case, the patient's friend is the designated proxy and has had clear instruction from the patient regarding her wish not to receive additional blood transfusions. Therefore, the patient should not receive a transfusion regardless of the family's preferences. (Choice A) A facility ethics committee is typically convened when no suitable surrogate decision-maker can be identified or there is disagreement among equal surrogates (eg, adult children). In this case, the patient has a single, properly designated surrogate decision-maker, whose decisions should be considered determinative. (Choices B and C) A next-of-kin surrogate does not take priority over a designated health care proxy. If there is no designated surrogate decision-maker, decisions typically fall to the next of kin as a default surrogate. A patient's spouse is usually considered the next of kin, although in the absence of a spouse, decisions may be made by other family members (eg, adult children, parents) in the order of relationship proximity. (Choice E) A physician should always make recommendations based on the best interests of the patient. However, with limited exception, the physician may not intervene over a patient's explicit refusal when given either directly by the patient or indirectly via an appropriate surrogate. Educational objective: A health care proxy is a person legally designated to make medical decisions if the patient loses decision-making capacity. The proxy takes priority over all other surrogate decision-makers, including family members. __________ References: Advance care planning: contemporary issues and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/30480109)

A 74-Year-Old Woman Is Brought to the Emergency Department by Ambulance