Avoiding Family Feuds: Responding to Surrogate Demands for Life-Sustaining Interventions

1999 ◽  
Vol 27 (1) ◽  
pp. 74-80 ◽  
Author(s):  
Ann Alpers ◽  
Bernard Lo
Keyword(s):  
Decision Making ◽  
Advance Directives ◽  
Family Members ◽  
Active Role ◽  
Best Interest ◽  
Ethical Guidelines ◽  
Medical Decisions ◽  
Case Examples ◽  
Surrogate Decision ◽  
Personal Community

The laws and ethical guidelines governing decision making for incompetent patients evolved from controversies in which family members refused life-sustaining interventions. These cases led to a consensus that advance directives to limit interventions should be respected and that a surrogate designated by the patient or specified by statute could refuse interventions, even when other relatives disagreed. Surrogate decision-making statutes and ethical principles about respect for delegated autonomy promote an active role for family members or other surrogates in medical decisions for incompetent patients. Inviting surrogates to participate actively in medical decisions recognizes the importance of the patient's personal community and assures that decisions will reflect the patient's own preferences and values.The standard approach to decisions for incompetent adults gives advance directives priority over a surrogate's substituted judgment, which in turn has priority over assessments of the patient's best interest. A patient may express advance directives by appointing a proxy, stating specific preferences, or articulating general values. We use case examples to illustrate the limitations of all three types of advance directives.

Ethics in Pediatric Anesthesiology

2018 ◽  
Author(s):  
Monica Shah ◽  
David Waisel
Keyword(s):  
Decision Making ◽  
Informed Consent ◽  
Ethics Committees ◽  
Decision Makers ◽  
Best Interest ◽  
Medical Decisions ◽  
Risks And Benefits ◽  
Surrogate Decision Makers ◽  
Surrogate Decision ◽  
Life Therapy

Ethical principles affect daily decision-making in pediatric anesthesiology. These medical decisions are interlaced with the ethical components of informed consent and obligations to the child and family. Informed consent in pediatrics includes the concepts of best interest, in which the parents or other surrogate decision-makers choose acceptable treatment for the child, and assent, which enables children to participate in decision-making to the best of their ability. Of equal significance to informed consent, the process of informed refusal requires anesthesiologists to more fully inform children and their guardians about risks and benefits while respecting refusal of assent and avoiding coercion. Pediatric considerations regarding end-of-life therapy are slightly different than adult considerations. To help resolve these ethical dilemmas, ethics committees are available for consultations to assist the medical team, family members, and patients in order to make the best decision for the child.

Surrogate decision making for unrepresented patients: Proposing a harm reduction interpretation of the best interest standard

2020 ◽  
Vol 15 (2) ◽  
pp. 57-64
Author(s):  
Phoebe Friesen ◽  
Nada Gligorov
Keyword(s):  
Decision Making ◽  
Harm Reduction ◽  
Well Being ◽  
The United States ◽  
Alternative Interpretation ◽  
Surrogate Decision Making ◽  
Best Interest ◽  
Medical Decisions ◽  
Best Interest Standard ◽  
Surrogate Decision

Unrepresented patients are individuals who lack decision makingcapacity and have no family or friends to make medical decisions for them. This population is growing in number in the United States, particularly within emergency and intensive care settings. While some bioethical discussion has taken place in response to the question of who ought to make decisions for these patients, the issue of how surrogate medical decisions ought to be made for this population remains unexplored. In this paper, we argue that standard applications of surrogate decision making principles in health care are not well suited to many unrepresented patients with long-term mental health diagnosis. We argue that when applied to this population, the substituted judgment standard, designed to preserve patient preferences and values, may lead to the exclusion of their preferences. We argue further that the application of the best interest standard runs the risk of leading to harmful cases of overtreatment or undertreatment. We offer an alternative interpretation of the best interest principle that is better able to promote the well-being of unrepresented patients, especially for those who lack capacity because of mental disorders. This alternative is based on the practices and principles of harm reduction and includes three components: emphasis on considering the expressed preferences of unrepresented patients, a focus on reducing harm as well as the delivery of clinical benefits, and a recognition of the importance of promoting trust.

Indiana Medical Resident’s Knowledge of Surrogate Decision Making Laws

2021 ◽  
pp. 0272684X2110047
Author(s):  
Stephanie Bartlett ◽  
Lyle P. Fettig ◽  
Peter H. Baenziger ◽  
Eliana N. DiOrio ◽  
Kayla M. Herget ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Treatment Options ◽  
Family Members ◽  
Veterans Affairs ◽  
Medical Residents ◽  
Surrogate Decision Making ◽  
Medical Decisions ◽  
Surrogate Decision ◽  
Va Hospitals

Introduction During the care of incapacitated patients, physicians, and medical residents discuss treatment options and gain consent to treat through healthcare surrogates. The purpose of this study is to ascertain medical residents’ knowledge of healthcare consent laws, application during clinical practice, and appraise the education residents received regarding surrogate decision making laws. Methods Beginning in February of 2018, 35 of 113 medical residents working with patients within Indiana completed a survey. The survey explored medical residents’ knowledge of health care surrogate consent laws utilized in Indiana hospitals and Veterans Affairs (VA) hospitals via clinical vignettes. Results Only 22.9% of medical residents knew the default state law in Indiana did not have a hierarchy for settling disputes among surrogates. Medical residents correctly identified which family members could participate in medical decisions 86% of the time. Under the Veterans Affairs surrogate law, medical residents correctly identified appropriate family members or friends 50% of the time and incorrectly acknowledged the chief decision makers during a dispute 30% of the time. All medical residents report only having little or some knowledge of surrogate decision making laws with only 43% having remembered receiving surrogate decision making training during their residency. Conclusions These findings demonstrate that medical residents lack understanding of surrogate decision making laws. In order to ensure medical decisions are made by the appropriate surrogates and patient autonomy is upheld, an educational intervention is required to train medical residents about surrogate decision making laws and how they are used in clinical practice.

In My Best Interest

2016 ◽  
Vol 34 (2) ◽  
pp. 160-165 ◽  
Author(s):  
Patricia A. Mayer ◽  
Bryn Esplin ◽  
Christopher J. Burant ◽  
Brigid M. Wilson ◽  
MaryAnn Lamont Krall ◽  
...  
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Medical Center ◽  
Specific Treatment ◽  
Living Will ◽  
Treatment Preferences ◽  
Power Of Attorney ◽  
Best Interest ◽  
Permanent Disability ◽  
Surrogate Decision

Background: Advance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration’s Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed. Objective: To describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs. Design/Setting: A descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014. Measurements: Responses to VA AD with emphasis on health care agents (HCAs) and LW responses. Results: Veterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA. Conclusion: Most of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.

Advance directives: Cancer patients’ preferences and family-based decision making.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 18-18
Author(s):  
Xing Li ◽  
Zhi-Huan Lin ◽  
Ying-Fen Hong ◽  
Xiao-kun Ma ◽  
Dong-hao Wu ◽  
...  
Keyword(s):  
Decision Making ◽  
Cancer Therapy ◽  
Cancer Patients ◽  
Advance Directives ◽  
Correlational Analysis ◽  
Invasive Treatment ◽  
Medical Decisions ◽  
Anti Cancer ◽  
Family Based ◽  
Chinese Cancer Patients

18 Background: Advance directives (ADs) are a sensitive issue among traditional Chinese people, who usually refrain from mentioning this topic until it is imperative. Medical decisions for cancer patients are made by their families, which might violate patients’ personal will. This study was aimed to examine the acceptance of ADs among Chinese cancer patients and their families and patient participation in this procedure. Finally, to analyze the moral risk involved. Methods: Participants included 412 adult cancer patients from 9 leading hospitals across China. An AD was introduced to the main decision makers for each patient; if they wished to sign it, the AD would be systematically discussed. A questionnaire was given to the oncologists in charge of each patient to evaluate the interaction between families and patients, patients’ awareness of their disease, and participation in an AD. Results: A total of 246 patients and their family members rejected systematic discussion of AD, the majority (95.5%) of whom were under anti-cancer treatment. An additional 166 patients or their families accepted the concept of an AD and signed an AD to give up invasive treatment. This decision was make shortly after termination of anti-cancer therapy. Correlational analysis revealed that patients living in villages and who were subordinate members in their families tended to accept an AD. Of these, only 24 patients participated in the decision making. Correlational analysis revealed that patients with a better financial situation, living in cities, and superordinate status in their families tended to participate in the AD discussion, as well as those who usually made medical decisions themselves. Nearly all the patients deciding their own AD knew their entire situation, including diagnosis and prognosis. For 101 patients, anti-cancer therapy was ended prematurely, with as many as 37 patients not told about their potential loss of health interests. Conclusions: ADs were widely accepted among Chinese cancer patients when anti-cancer therapy was terminated. Most cancer patients were excluded from the discussion of an AD. Thus, AD could be formally introduced to the family of Chinese cancer patients after termination of anti-cancer therapy.

scholarly journals Implantable cardioverter defibrillator (ICD) functionality: patient and family information for advanced decision-making

2019 ◽  
pp. bmjspcare-2019-001835
Author(s):  
Loreena Michelle Hill ◽  
Sonja McIlfatrick ◽  
Brian Taylor ◽  
Lana Dixon ◽  
Donna Fitzsimons
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Medical Profession ◽  
Treatment Plan ◽  
Qualitative Interviews ◽  
Family Members ◽  
Implantable Cardioverter Defibrillators ◽  
Framework Analysis ◽  
Best Interest ◽  
Joint Decision

As the number of implantable cardioverter defibrillators (ICDs) implanted continues to rise, there is a growing challenge to ensure patients and family members are adequately equipped for involvement in future end-of-life decisions concerning their device.ObjectiveTo explore patients’, family members’ and professionals’ attitudes and understanding towards discussing ICD deactivation.MethodsCase study approach using qualitative interviews and framework analysis. A total of 29 qualitative interviews were undertaken, involving patients with a device, family members and healthcare professionals. Interviews were audio-recorded, transcribed verbatim and analysed using framework analysis. Data were triangulated with information obtained from the patients’ medical records (n=10).ResultsThree main themes: (1) Professionals were reluctant to engage in conversations concerning deactivation, particularly prior to implantation, believing this was in the patient’s best interest. (2) Patients and family members had limited understanding of the implanted device and its functions. It was frequently perceived as ‘life-saving’ with any negativity of the shock experience seen as acceptable. (3) All patients wanted the opportunity to discuss deactivation when death was imminent, but were indecisive whether family members should be involved. Similarly, some patients felt the decision to deactivate rested solely with the medical profession while others felt it should be a joint decision between patient, family and clinical team.ConclusionsPatients and family members require improved communication and information concerning their future treatment plan and functionality of an ICD. A proactive approach to discuss deactivation would enable shared clinical decision-making in the advanced stages of illness.

In the patient’s best interest: appraising social network site information for surrogate decision making

2018 ◽  
Vol 44 (12) ◽  
pp. 851-856 ◽  
Author(s):  
Shahla Siddiqui ◽  
Voo Teck Chuan
Keyword(s):  
Decision Making ◽  
Social Network ◽  
Mental Capacity ◽  
Surrogate Decision Making ◽  
Best Interest ◽  
Social Network Site ◽  
Code Of Practice ◽  
Network Site ◽  
Surrogate Decision ◽  
Mental Capacity Act

This paper will discuss why and how social network sites ought to be used in surrogate decision making (SDM), with focus on a context like Singapore in which substituted judgment is incorporated as part of best interest assessment for SDM, as guided by the Code of Practice for making decisions for those lacking mental capacity under the Mental Capacity Act (2008). Specifically, the paper will argue that the Code of Practice already supports an ethical obligation, as part of a patient-centred care approach, to look for and appraise social network site (SNS) as a source of information for best interest decision making. As an important preliminary, the paper will draw on Berg’s arguments to support the use of SNS information as a resource for SDM. It will also supplement her account for how SNS information ought to be weighed against or considered alongside other evidence of patient preference or wishes, such as advance directives and anecdotal accounts by relatives.

The Medical Surrogate as Fiduciary Agent

2017 ◽  
Vol 45 (3) ◽  
pp. 402-420
Author(s):  
Dana Howard
Keyword(s):  
Decision Making ◽  
Advance Care Planning ◽  
Care Planning ◽  
Surrogate Decision Making ◽  
Best Interest ◽  
New Approach ◽  
Novel Approach ◽  
Advance Care ◽  
Surrogate Decision

Within bioethics, two prevailing approaches structure how we think about the role of medical surrogates and the decisions that they must make on behalf of incompetent patients. One approach views the surrogate primarily as the patient's agent, obediently enacting the patient's predetermined will. The second approach views the surrogate as the patient's custodian, judging for herself how to best safeguard the patient's interests. This paper argues that both of these approaches idealize away some of the ethically relevant features of advance care planning that make patient preferences so inscrutable and surrogate decision-making so burdensome. It proposes a new approach to surrogate decision-making, the Fiduciary Agency Approach. On this novel approach, the surrogate has authority to not only act on the patient's behalf as the patient's agent but also to decide on the patient's behalf as the patient's fiduciary. One upshot of this new approach is that surrogates must sometimes go against the expressed dictates of the patients' advance directives not necessarily because doing so would be in the patient's best interest but rather because doing so would best represent the patients' will.

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