A 26-year-old primigravida at 38 weeks gestation is admitted to the hospital due to preeclampsia with severe features. She undergoes an emergency cesarean delivery of a healthy newborn. After delivery, the patient continues to have uncontrolled hypertension and suffers an ischemic stroke. She is intubated and placed on full ventilator support. On day 3 of hospitalization, the patient remains minimally responsive to most stimuli. She has no advance directive. The physician explains the clinical findings and options for care to the patient's husband and parents. The husband says he met his wife 2 years ago and does not recall discussing life-sustaining medical treatment with her. The patient's parents state that it would be best to continue life support because the patient just became a mother. In further discussion with the family, which of the following would be most important for the physician to address?

Question

A 26-year-old primigravida at 38 weeks gestation is admitted to the hospital due to preeclampsia with severe features.  She undergoes an emergency cesarean delivery of a healthy newborn.  After delivery, the patient continues to have uncontrolled hypertension and suffers an ischemic stroke.  She is intubated and placed on full ventilator support.  On day 3 of hospitalization, the patient remains minimally responsive to most stimuli.  She has no advance directive.  The physician explains the clinical findings and options for care to the patient's husband and parents.  The husband says he met his wife 2 years ago and does not recall discussing life-sustaining medical treatment with her.  The patient's parents state that it would be best to continue life support because the patient just became a mother.  In further discussion with the family, which of the following would be most important for the physician to address?

Quizplus · Accepted Answer

In the absence of an advance directive (legal documentation of a patient's preferences if he or she becomes incapacitated), management of an incapacitated patient should be based on the principle of substituted judgment. This requires the surrogate decision-maker to make medical decisions based on his or her understanding of what the patient would have wanted if she had capacity and was faced with the specific decision. Although the husband's and the parents' preferences for the patient's treatment can be discussed, the overriding consideration is what the patient herself would have wanted (Choices B and D); in other words, would the patient want to continue on life support? In this case, the surrogate would base the decision on his or her best understanding of how the patient's values and beliefs would influence her wishes regarding life-sustaining interventions. If the family is unable to arrive at a consensus on what the patient would have wanted, the priority decision-maker is usually the spouse, followed by the parents. (Choice C) The likelihood of a meaningful recovery is an important consideration, but most crucial would be understanding the patient's wishes, including determining if the surrogate decision-maker believes that the patient herself would prioritize the likelihood of a meaningful recovery in her decision. For example, if the surrogate decision-maker understands that the patient would want life-sustaining treatment regardless of the likelihood of recovery, her wishes for continued life support should be honored. (Choice E) Although the risk of medical complications with prolonged mechanical ventilation should be discussed as part of an informed consent discussion, the priority is to determine the family's understanding of the patient's beliefs and values relevant to decisions about life-sustaining treatment. Educational objective: In the absence of an advance directive, management of an incapacitated patient is based on the principle of substituted judgment. The surrogate decision-maker is obligated to base decisions on his or her best judgment of what the patient would have wanted. References: Capacity for preferences: respecting patients with compromised decision-making. (http://www.ncbi.nlm.nih.gov/pubmed/29806903)

A 26-Year-Old Primigravida at 38 Weeks Gestation Is Admitted to the Hospital