A 65-year-old man is brought to the emergency department by a friend who found the patient disoriented in his apartment. The patient's medical history includes chronic obstructive pulmonary disease, hypertension, coronary artery disease, and tobacco use. He is unmarried and lives alone. The friend says that the patient has a sister who lives in the area but is unaware of when they last spoke. The friend has known the patient for 5 years and says that they are "good buddies." He tells the physician that they have discussed dying and that he believes the patient would prefer to "go naturally" and would refuse any heroic measures, including "being hooked up to a ventilator." Temperature is 39 C (102.2 F), blood pressure is 120/80 mm Hg, pulse is 105/min, and respirations are 24/min. Oxygen saturation is 88% on room air and 93% on 2 L of oxygen. The patient is somnolent and unable to answer questions. The lungs have bilateral wheezing and decreased breath sounds. Chest x-ray reveals a right lower lobe infiltrate. Appropriate bronchodilator and antibiotic therapies are initiated. The physician is concerned about the need for intubation if the patient does not respond to initial treatment in the next 2-3 hours. Which of the following is the most appropriate course of action?

Question

A 65-year-old man is brought to the emergency department by a friend who found the patient disoriented in his apartment.  The patient's medical history includes chronic obstructive pulmonary disease, hypertension, coronary artery disease, and tobacco use.  He is unmarried and lives alone.  The friend says that the patient has a sister who lives in the area but is unaware of when they last spoke.  The friend has known the patient for 5 years and says that they are "good buddies."  He tells the physician that they have discussed dying and that he believes the patient would prefer to "go naturally" and would refuse any heroic measures, including "being hooked up to a ventilator."  Temperature is 39 C (102.2 F), blood pressure is 120/80 mm Hg, pulse is 105/min, and respirations are 24/min.  Oxygen saturation is 88% on room air and 93% on 2 L of oxygen.  The patient is somnolent and unable to answer questions.  The lungs have bilateral wheezing and decreased breath sounds.  Chest x-ray reveals a right lower lobe infiltrate.  Appropriate bronchodilator and antibiotic therapies are initiated.  The physician is concerned about the need for intubation if the patient does not respond to initial treatment in the next 2-3 hours.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

11ec160b_3659_d18d_9249_2dab0ded9655_MD0001_00 This patient has acute pneumonia complicated by hypoxemia and confusion. He is noncommunicative and unable to give consent regarding invasive ventilation. In such cases, consent can often be obtained from an advance directive, either a living will (ie, document specifying consent for certain life-prolonging interventions) or designated surrogate decision-maker (eg, durable power of attorney) if available. In the absence of a living will or designated surrogate, decision-making falls to the next of kin (typically the patient's spouse, adult child, parent, or adult sibling determined by the proximity of relationship). Therefore, this patient's sister (next of kin) should be contacted regarding consent to intubate. In nonemergent situations, surrogates are responsible for making decisions based on what they believe the patient would want (ie, substituted judgment) and the patient's best interest. (Choice B) A facility ethics committee may be convened when equal surrogate decision-makers (eg, multiple adult children) disagree or there is reason to suspect that the surrogate is not acting in the patient's interest. In this case, the need to contact the patient's sister is straightforward and does not require ethics committee input. (Choice C) The patient's friend does not have priority over next of kin for decision-making. If no family members are available, then the advice of his friend could be considered in substituted judgment. (Choice D) In an emergency, the physician should use clinical judgment and act promptly, and can do so without consent if necessary. However, in this case, intubation is not emergent, so an effort should be made to contact the patient's sister first. (Choice E) Waiting for the patient's mental status to improve would be inappropriate, given that his respiratory status may deteriorate rapidly. Educational objective: When a patient is unable to give consent for care and does not have a designated surrogate, decision-making capacity falls to the next of kin, generally determined by the proximity of relationship. In an emergency, the physician can treat an incapacitated patient without obtaining consent.

A 65-Year-Old Man Is Brought to the Emergency Department by a Friend