A 79-year-old woman with acute-onset shortness of breath is brought to the emergency department by her husband and adult son. The patient has had 2 recent hospitalizations for aspiration pneumonia over the previous 6 months. Her medical issues include Alzheimer disease, hypertension, type 2 diabetes mellitus, and severe chronic obstructive pulmonary disease. Medications include lisinopril, glipizide, galantamine, albuterol, and metered-dosed inhaler ipratropium bromide. Temperature is 37.8 C (100 F), blood pressure is 85/60 mm Hg, pulse is 114/min, and respirations are 28/min. Pulse oximetry is 70% on room air and 85% on 100% nonrebreather mask. Examination shows dry mucous membranes, right lung base crackles, and tachycardic heart sounds. She is stuporous and minimally responsive. Intravenous fluids and antibiotics are administered, but her respiratory status continues to deteriorate. The patient's son, who has a durable power of attorney for health care, states that his mother would not want to be intubated and requests that she be made comfortable. A review of the previous medical chart shows no advance directives. The patient's husband agrees with the patient's son, but when the patient's daughter arrives, she insists that "everything should be done" and that "Mom would not want to die like this." Which of the following is the most appropriate next step in management of this patient?

Question

A 79-year-old woman with acute-onset shortness of breath is brought to the emergency department by her husband and adult son.  The patient has had 2 recent hospitalizations for aspiration pneumonia over the previous 6 months.  Her medical issues include Alzheimer disease, hypertension, type 2 diabetes mellitus, and severe chronic obstructive pulmonary disease.  Medications include lisinopril, glipizide, galantamine, albuterol, and metered-dosed inhaler ipratropium bromide.  Temperature is 37.8 C (100 F), blood pressure is 85/60 mm Hg, pulse is 114/min, and respirations are 28/min.  Pulse oximetry is 70% on room air and 85% on 100% nonrebreather mask.  Examination shows dry mucous membranes, right lung base crackles, and tachycardic heart sounds.  She is stuporous and minimally responsive.  Intravenous fluids and antibiotics are administered, but her respiratory status continues to deteriorate.  The patient's son, who has a durable power of attorney for health care, states that his mother would not want to be intubated and requests that she be made comfortable.  A review of the previous medical chart shows no advance directives.  The patient's husband agrees with the patient's son, but when the patient's daughter arrives, she insists that "everything should be done" and that "Mom would not want to die like this."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient is incapacitated by medical illness and cannot make medical decisions for herself. In the absence of an advance directive to guide medical decision-making, physicians must work with a surrogate decision maker. A surrogate whom the patient has legally designated as durable power of attorney for health care (DPOA-HC) prior to incapacitation takes precedence over default surrogates. In most states, default surrogates are considered in the following order of descending priority: Spouse, adult children, parent, adult sibling, nearest living relative, and close friend. The patient's son is DPOA-HC and is the surrogate decision maker for his incapacitated mother. Although efforts can be made to facilitate reconciliation between the patient's son and daughter, the son has been designated as the patient's surrogate and as such his substituted judgment on behalf of the patient takes priority over the daughter's wishes. (Choice A) Although consensus is always preferred, it may not be possible in situations of medical urgency. The patient's son is the DPOA-HC; therefore, his surrogate decision takes precedence. (Choice B) The hospital ethics committee may be consulted in uncertain cases. However, in this case, the urgency of the patient's condition, the preexistence of a clearly assigned DPOA-HC, and the relative consensus between the patient's son/DPOA-HC and husband make an ethics consult impractical and unnecessary. (Choice C) The surrogate's decision must be respected; proceeding with more aggressive treatment is inappropriate. (Choice D) There is no basis for contesting the son's status as the DPOA-HC; therefore, a court-appointed guardian is unnecessary. Educational objective: In the absence of an advance directive, a surrogate decision maker helps guide medical treatment if a patient is incapacitated. A legally designated durable power of attorney for health care takes precedence over other potential surrogates. References: Advance directives and outcomes of surrogate decision making before death. (http://www.ncbi.nlm.nih.gov/pubmed/20357283) Legal fundamentals of surrogate decision making. (http://www.ncbi.nlm.nih.gov/pubmed/22474149)

A 79-Year-Old Woman with Acute-Onset Shortness of Breath Is Brought