Board Review

An 83-year-old man is admitted to the hospital with fever, severe dyspnea, and hypoxemia due to pneumonia. He is lethargic, disoriented, and lacks capacity to make decisions. Medical history is significant for chronic bronchitis. Respiratory failure and need for mechanical ventilation are imminent. There is no advance directive. Two surviving adult children are struggling with making decisions about his care, especially regarding mechanical ventilation.

Which of the following is the most appropriate course of action to facilitate a decision on this patient's care?

A) Ask the patient's children to make a decision based on the patient's best interests

B) Ask the patient's children to make a decision based on what they feel is correct

C) Ask the patient's children what the patient would do if he were able to make a decision

D) Encourage the patient's children to speak to a social worker

E) Wait for the court to appoint a guardian who will make a decision

Answer: C - Ask the patient's children what the patient would do if he were able to make a decision

Objective: Facilitate decision-making for a patient who lacks decision-making capacity.

Key Point

When a patient lacks decision-making capacity and does not have an advance directive, a surrogate who best knows the patient's health care values, goals, and preferences must make decisions.

The most appropriate course of action is to ask this patient's surrogates, his children, to relate what decisions the patient would make if he were capable. In the case of a patient who lacks decision-making capacity, a surrogate must guide decision making. If such a patient has an advance directive, the person named in that advance directive is the most appropriate (and legal) surrogate. If the patient's advance directive does not name a surrogate, or if the patient does not have an advance directive, the best surrogate is the person who best knows the patient's health care values, goals, and preferences; however, many U.S. states stipulate a hierarchy of surrogate decision-makers in the absence of an advance directive (for example, the patient's spouse, followed by an adult child, and so forth). Surrogate decision making in the absence of an advance directive is common, as only about 20% of U.S. adults have advance directives in place. In the case of this patient, the two surviving adult children are the most appropriate surrogates. They have ethical and legal obligations to make decisions based on their father's health care–related values, goals, and preferences (that is, substituted judgment). The physician should ask what decision their father would make about his care if he were able.

Many surrogates are often aware of patients' values, goals, and preferences; however, if these values, goals, and preferences are unknown, a surrogate should make decisions in the patient's best interests.

A surrogate should not make decisions based on his or her own values, preferences, or what he or she feels is the correct course of action, as these views may differ from those of the patient.

Because nonmedical personnel may not be able to accurately convey specific medical details that might influence decision making, physicians should not defer these discussions to others (for example, social workers). Additionally, engaging in therapeutic decision making is an inherent professional responsibility of the attending physician.

Court-appointed guardians are selected for patients who lack decision-making capacity; whose health care–related values, goals, and preferences are unknown; and for whom no obvious surrogate decision-maker exists. In the case of this patient, surrogates are available.

Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. . 2012 Jan 3;156(1 Pt 2):73-104. Link Out