A 67-year-old man is brought to the emergency department by ambulance due to altered mental status. He was having dinner with his daughter when he suddenly became confused and slumped over. The patient has a history of atrial fibrillation for which he takes an oral anticoagulant. He is widowed and lives with his daughter. Blood pressure is 208/113 mm Hg, pulse is 64/min and irregular, and respirations are 15/min. Oxygen saturation is 88% on room air. The patient is obtunded and unable to follow commands. Pupils are midsized and do not respond to light. The physician determines that intubation is necessary at this time to protect the patient's airway and asks for consent from the daughter and older son who are at the bedside. They tell the physician that the patient does not have an advance directive and they are unsure how to proceed. Which of the following is the most appropriate next step in decision-making for this patient?

Question

A 67-year-old man is brought to the emergency department by ambulance due to altered mental status.  He was having dinner with his daughter when he suddenly became confused and slumped over.  The patient has a history of atrial fibrillation for which he takes an oral anticoagulant.  He is widowed and lives with his daughter.  Blood pressure is 208/113 mm Hg, pulse is 64/min and irregular, and respirations are 15/min.  Oxygen saturation is 88% on room air.  The patient is obtunded and unable to follow commands.  Pupils are midsized and do not respond to light.  The physician determines that intubation is necessary at this time to protect the patient's airway and asks for consent from the daughter and older son who are at the bedside.  They tell the physician that the patient does not have an advance directive and they are unsure how to proceed.  Which of the following is the most appropriate next step in decision-making for this patient?

Quizplus · Accepted Answer

11ec160b_365a_94de_9249_09812552f3ab_MD0001_00 This patient is critically ill and unresponsive, likely due to an intracerebral hemorrhage. Endotracheal intubation for airway protection is indicated, and consent must be obtained as quickly as possible. Procedural consent for an incapacitated patient can often be obtained from an advance directive, either a living will (ie, document specifying consent for certain life-prolonging interventions) or designated proxy decision-maker (eg, durable power of attorney). However, in the absence of an advance directive, decision-making falls to the closest family member (ie, next of kin). Next of kin authority is determined by proximity of relationship; typically, the patient's spouse has precedence, but adult children are the next of kin for this patient who is widowed. As with all surrogate decision-makers, the next of kin is responsible for making decisions based on what they believe the patient would want if he or she were competent to make the decision (ie, substituted judgement), rather than their own preferences. (Choices A, B, and C) Next of kin is not determined by birth order or current living situation; both adult children have equal standing and should be encouraged to make decisions jointly. Although all surrogates are charged to make decisions with consideration to the patient's best interest, the primary guiding principle is substituted judgment (ie, what the patient would want). (Choice E) Although a physician may institute emergency life-saving measures without consent if no surrogate decision-maker is available, the physician does not know what the patient would have wanted. Consent from the next of kin is preferable. Educational objective: Consent for an incapacitated patient can often be obtained from an advance directive, either a living will or designated proxy. In the absence of an advance directive, decision-making falls to the next of kin, who is responsible for making decisions based on what they believe the patient would want (substituted judgement).

A 67-Year-Old Man Is Brought to the Emergency Department by Ambulance