Case Scenario An 88-year-old woma...

Case Scenario

An 88-year-old woman was lately admitted to our inpatient family practice service in an unresponsive state, after having a hit She had a history of angina, congestive heart failure, diabetes, hypertension, atrial fibrillation, and an above-knee amputation, and she had been homebound upon several occasions over the years, this woman had told her family physician that she did not want to pass through cardiopulmonary resuscitation (CPR), be propose on a respirator, or have her life extended mechanically if she became terminally ill. Her physician had documented these wishes in the office chart, as well as in the hospital medical record, during several admissions athwart the past two years. During each admission, her digest status was "Do Not Resuscitate" (DNR) However, the patient had not ever signed a formal advance directive statement or assigned durable power of attorney for her health care to anyone.

During the passing from hand to hand admission, the resident on the service and the patient's family physician spoke with her nearest relative, a niece, about the patient's condition, and brought up the issue of digest status. The niece claimed that she had power of attorney, insisted that "everything" be done to save her aunt's life, and was outraged that a DNR status would on the same level be considered. She asserted that, "All you doctors want to know is whether to fit her for a coffin or an urn" The physicians forward the service were not permanent whether to respect the patient's clearly exhibited consistent wishes and risk the anger of the niece and a possible lawsuit, or fare along with the niece's directive. The hospital's ethics committee was confered and the determination was made that it would be discreet to follow the niece's wishes about decision-making for her aunt. Should we have done anything differently?

Commentary

In this case scenario, the family physician prosperously performed a task that many times is forgotten during physician-patient visits--the physician at short intervals discussed with this patient her wishes for end-of-life care. The conversations specifically included her meditations about respirators, CPR, and other potential life-prolonging treatments. The physician documented those wishes in the one and the other outpatient and inpatient medical charts onward several occasions. It would have been helpful if the patient had formalized those wishes by dint of signing an advance directive. unruffled so, this patient seems to have left no doubt about her views, and she maintained them above the years. The question here was in what way much importance should be assigned to the patient's wishes when the no other than family member present demanded actions contrary to them.

an information not included in this case scenario would be helpful in making a decision--i.e., what was the prognosis for this patient following the stroke? Because of her complicated medical history, it was unlikely that attempted CPR would ultimately be fortunate At least one retrospective studious mood has shown that chronically ill patients undergoing CPR in the setting of an acute insult solely have about a 4 percent chance of surviving protracted enough to leave the hospital. (1) level in those few cases, the patients do not necessarily leave the hospital in better shape than when they were admitted. In fact, common of the contraindications for CPR as it was being exhibited in the 1960s was that the patient should not be near the [i]finale[/i] of life due to an incurable disease. (2)

The obligation of physicians to withhold treatments that are likely to be of no real benefit to the patient was not changed by the agency of the Patient Self-Determination Act of 1990 This act requires hospitals to ask all patients onward admission if they have advance directives and to assist in preparing them if they do not. As they decide about advance directives, patients and families should be helped to understand that CPR can have painful results such as needles, catheters, pressors, and ventilators that may clinch no real benefit for a patient dying of a chronic disease.

Another piece of missing information is the representation of power of attorney held at the niece. A durable power of attorney for health care would carry weight in this case, if it be not that the patient never signed the same The physicians should have demanded that the niece produce the power of attorney to such a degree that its relevance to the medical situation could be assessed. However, uniform if the niece could originate evidence that she is the designated health care substitute her desires should not take supremacy over those of the patient. The niece in this case was clearly distressed from the suddenness of her aunt's decline. This distress is belonging to all in family members even when the close is foreseen after a protracted illness. The goals of care have for in such a manner long been life prolongation and comfort that it can be difficult to narrow that focus to alone keeping the patient comfortable. Certainly the cultural backgrounds of the patient and her niece could have had a lusty effect on their opinions.

For any health care lieutenant there are at least three different standards for surrogate decision-making. The chiefly ethical standard is to ask the question, "What would the patient fix upon if she were able to decide for herself?" Using this standard, the family or friends who know the patient make a substitute mother-wit based not on their wishes further on those previously expressed according to the patient. (3) If there are no known patient views, the commissioner decides in the best interests of the patient. The next to the first standard calls on the decision-makers to weigh the benefits and weights of a treatment and decide if it will improve the patient's overall situation. The third and least useful ethical standard is to make decisions based forward the wishes of the substitute or the rest of the family. If the surrogate decision-maker is also the primary caretaker, it may be impossible to separate these wishes from the patient's interests because riddles for the caretaker often translate into point in disputes for the patient.