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PROBLEMS AND PROXIES: WHEN YOU DON’T HAVE AN (ABLE) SURROGATE

PROBLEMS AND PROXIES: WHEN YOU DON’T HAVE AN (ABLE) SURROGATE. Ethics Champions June 4, 2014 Ann K. Suziedelis, PhD VP Spiritual Care & Ethics. SCENARIOS. A decisionally incapacitated patient with no known family or friends; or

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PROBLEMS AND PROXIES: WHEN YOU DON’T HAVE AN (ABLE) SURROGATE

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  1. PROBLEMS AND PROXIES:WHEN YOU DON’T HAVE AN (ABLE) SURROGATE Ethics Champions June 4, 2014 Ann K. Suziedelis, PhD VP Spiritual Care & Ethics

  2. SCENARIOS A decisionally incapacitated patient • with no known family or friends; or • with no designated decision maker and family members who cannot agree about treatment; or • with a designated decision maker, but concerns about the decision maker’s capacity to do so.

  3. THE CASE OF MRS. T. Ms. T is an 86 year old lady, whose medical history includes dementia, hypertension, CHF and a recent diagnosis of pulmonary hypertension. She also has hyperthyroidism, with a large goiter for which she has refused treatment. Prior to admission, she was able to walk with a walker and eat independently, but required assistance with all other ADLs. She presented to the ER with shortness of breath and was diagnosed with pneumonia and a urinary tract infection.

  4. Shortly after admission she began refusing medications and food. Her level of consciousness has diminished. She has been transferred to the ICU with sepsis. She has been intubated, extubated, and re-intubated. Several ENT surgeons have now evaluated her for tracheostomy, but deem her to be too high risk because of the goiter. Ms. T. has also had several thoracenteses, with chest tubes, for recurrent pleural effusions. She is now ventilator and vasopressor dependent.

  5. CAST OF CHARACTERS • Daughter, Rose, with whom she lived until three years ago. Rose was at one time the agent named in a DPOA-HC. • Daughter Violet, who took Mrs. T to her house a year ago for a visit, and never brought her back to Rose. New DPOA-HC now, naming Violet as Agent. • Daughter, Daisy • Daughter, Marigold • Son, Dexter, who lives out of state.

  6. CONVERSATION(S) • Medical conversations with siblings, physicians, and nurses • Palliative Care • Spiritual Care • Family Meetings with Ethics added

  7. CONCERNS • Is Violet acting in Mrs. T.’s best interest? • Is Violet following the DPOA-HC, where Mrs. T. states that: “I specifically reject any heroic life-saving measure and equipment or any apparatus to sustain life wherein my attorney in fact [Agent] determines that it is not in my best interest to undergo such treatment.” • Does Violet herself have the capacity to make decisions as important as these?

  8. QUESTIONS • What defines “best interest”? • Can we negate a DPOA-delegated Agent? If yes, how, and by what criteria? • Who should be involved in determining whether a decision maker is acting in a patient’s best interest? • How far should we go in limiting care that physicians have determined to be futile or not beneficial?

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