An 82-year-old man is admitted to the hospital in the middle of the night. He is noncommunicative and has multiple comorbidities, including end-stage lung cancer. The patient has neither a designated power of attorney nor an advance directive on file. His wife of many years, who is at the hospital with him, has an extensive conversation with the physician in charge of his care. During the conversation, she says that, on several occasions, the patient said not to resuscitate him if he were near death because he did not want to live "attached to machines or brain dead." She says that he just wants to die in peace when the time comes. What would be the most appropriate course of action if the patient enters ventricular fibrillation?

Question

An 82-year-old man is admitted to the hospital in the middle of the night.  He is noncommunicative and has multiple comorbidities, including end-stage lung cancer.  The patient has neither a designated power of attorney nor an advance directive on file.  His wife of many years, who is at the hospital with him, has an extensive conversation with the physician in charge of his care.  During the conversation, she says that, on several occasions, the patient said not to resuscitate him if he were near death because he did not want to live "attached to machines or brain dead."  She says that he just wants to die in peace when the time comes.  What would be the most appropriate course of action if the patient enters ventricular fibrillation?

Quizplus · Accepted Answer

11ec160b_3657_6089_9249_cfb930b11b2b_MD0001_00 This patient is unable to communicate his wishes regarding his care and does not have a prepared statement of his wishes (ie, advance directive) or designated surrogate decision-maker (eg, durable power of attorney). In such cases, decision-making falls to the next of kin (also called default surrogate). The order of next of kin is determined by the proximity of relationship; in most jurisdictions, priority goes to the patient's spouse, adult children, parents, and adult siblings, sequentially. The next of kin is responsible for making decisions based on what they believe the patient would want (ie, substituted judgment) and the patient's best interest. In this case, the patient's wife indicates that he had expressed his wishes not to be resuscitated (ie, basic life support [rescue breathing, chest compressions], advanced cardiac life support [ACLS] [mechanical ventilation, defibrillation]). Therefore, in case of ventricular fibrillation or another malignant arrhythmia, this patient should not be resuscitated. Comfort measures should be provided as appropriate, and staff should avoid disrupting the family's final moments with the patient. (Choice B) As next of kin, the patient's wife has the authority to make decisions for the patient. Nothing in this case suggests inadequate or insincere decision-making by the wife, and her decisions should be respected. (Choice C) According to the patient's wishes, he should not receive cardiopulmonary resuscitation measures. However, nonresuscitative supportive care (eg, supplemental oxygen) and comfort measures (eg, pain medication) should continue as usual and not be withheld. (Choice D) Court proceedings are time-consuming and disruptive. They are generally necessary only when a suitable surrogate cannot be identified or when there are intractable disagreements among surrogates (eg, multiple adult children). (Choice E) Treatment of ventricular fibrillation with antiarrhythmic medications is considered part of the ACLS resuscitation algorithm and is generally excluded as part of a do-not-resuscitate order. In general, partial algorithm implementation should not be considered in the absence of specific guidance from the patient or surrogate. Educational objective: When a patient is unable to communicate his or her wishes regarding care and does not have an advance directive or designated surrogate decision-maker, decision-making falls to the next of kin (eg, spouse). The next of kin is generally determined by the proximity of relationship and is responsible for making decisions based on what they believe the patient would want and the patient's best interest.

An 82-Year-Old Man Is Admitted to the Hospital in the Middle