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What do you do if family is divided equally on life support (ethics)
Interview Question: What do you do if family is divided equally on life support
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The crux of any such question is "what would the patient's wishes be in this situation." The family member you listen to is the one who can provide the greatest insight into this. I would think this would be the spouse in most cases.
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Identify who has POA and do what they want.
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Oh okay. It was just on a list of questions for my interview which I need to know how to answer and I'm still stuck on this. I did say that it would be what the patient wished, but they said "BUT WHAT IF" and I am stumped after that
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Yes! ethically. If half want him on and half his offspring want him off - assuming that I've already referred them to people who can educate them on this, looked through the files of the patient and discovered - wa la! He did not leave a specific name to carry out his health wishes, etc.
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I always get amused when people try to dodge the question by bringing up protocol, rather than address what they're obviously getting at. Do they seriously expect the adcom will be satisfied with "consult x in these situations"? If ethics were that easy why bother.
Anyways, after going through the criteria you mentioned (educating the relatives, etc.), I would probably say leave the patient on. Removing life support seems like a positive intervention in the patient's current condition. Because the "default" state of care seems to be to do nothing rather than something here (where the patient's condition is stable), and only with patient (or in this case, relatives') approval can an intervention be done, an even split would leave the decision in the default state. In other words, you'd need a majority to trigger a positive intervention like this one.
That's what my intuition tells me- I'm curious to see what you think.
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I have a personal bias where I believe that the patient should be removed from life support should the brain no longer function/should he/she no longer be breathing on her own after multiple consultations that nothing more can be done. It was hard for me to understand what to do here with that pre-existing belief. But I do understand where you care coming from. Thank you!
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Depends on the state. Many have a hierarchy, but some do not. In CA for example, legally, all relatives have equal say, ranging from spouse to second cousin Jim. Even in states that have an explicit hierarchy, people can be equal (spouse trumps adult children, fine, but what if there is no spouse and there's 2 adult children who disagree?).
In the real world, assuming there isn't a designated healthcare power of attorney, you get the family together and you ask them to designate someone to be in charge. Then you ask them to discuss what the patients wishes would be in this situation. If they can come to some kind of consensus, we do that. If they can't come to any consensus, and the family is evenly split despite several discussions, then you get the hospital ethics committee involved. The ethics committee hears from both halves of the family as well as the treatment team and comes to a determination, then we do that.
That said, if the "brain no longer function" at all, it's a really simple answer (outside of one very fringe, bizarre, case that I still don't know how the judge ruled how he did). If the patient is truly brain dead, they are legally deceased, and you don't need family permission to disconnect the corpse from the ventilator. They may be angry, but you're 100% legally in the right at that point.
It only gets hinky if they still have some lower brain functions. If that is the case... it is a LOT more difficult than the above assertion to just leave the patient on as a default option. Patients can't just stay with an endotracheal tube in the ICU forever. That is a waste of time, money, and puts the patient (or whats left of him at least) at high risk for a million different complications. The only options at that point are either to disconnect life support and allow them to die peacefully, or pursue aggressive measures with a tracheostomy, a PEG tube, and then try to place the patient in a long-term acute care center. The family/ethics committee has to pick one of the two after some reasonable amount of time, because the ICU isn't the place to just park grandpa forever.
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thank you!!!
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I don't think the protocol is a bad thing or an inappropriate answer. You wouldn't just perform a procedure on someone without consent, so obtaining consent should always be the first thing you do, and in this instance the POA has that legal and ethical ability. This is not the Senate where an up or down vote by the family will result in consent or lack of consent. The DPOA is the person for the purposes of consent.
So I would explain the pros and cons, the prognosis , and then try to sell that to the DPOA and family if they want. I would probably give them some time to make the decision and then I would ask for the decision from DPOA. If the DPOA can't make up his or her mind , well then the status qou remains until the patient crashes or recovers. This is really not that controversial of a question.
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You meet with the family members and the team to iron out what the underlying problems are. Sometimes the issue is lack of understanding about the prognosis, sometimes it's denial, and sometimes the argument around life support is a proxy battle over deeper family issues. Most people are reasonable and can reach consensus once the issues are hashed out.
In the rare instance when the differences are irreconcilable, that's when you turn to the law, POA hierarchy, etc.
In the rare instance when the differences are irreconcilable, that's when you turn to the law, POA hierarchy, etc.
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If everyone had a DPOA, there wouldn't be an issue. The overwhelming majority of people under 75 don't have one though. If they have a spouse, it's still pretty easy, though if the adult children disagree with the wife and if you're in a state without an explicit hierarchy of decision-makers, you're still between a rock and a hard place.
That's why hospitals have ethics committees.
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Indeed. I personally have a few "what would you do if...?" questions in my toolkit, and every one of them has a followup in case someone pulls the "I'd just follow protocol", or "How I was trained" or "I'd do what the law says".
At some point kids, you will have to justify your thinking. Don't look for shortcuts, this how people end up on wait lists, terminally.
At some point kids, you will have to justify your thinking. Don't look for shortcuts, this how people end up on wait lists, terminally.
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Thank you everyone!!!
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To be honest, "I'd do what the law says" and "I'd follow the hospital protocols" are probably the correct answer in this specific question more of ten than not. Admitting the limitations of ones knowledge is an important skill too. Stick me in an interview in a state with laws I'm not aware of, and I wouldn't be able to answer what the "right" answer is... and I've had 8 years of training on top of the premeds. Mind you, if someone is asking me to have ICU family meetings again, my career is a fair bit off track.
I still remember an interview I had for medical school at the University of Albany, ~9 years ago. Interviewer must have been close to 80, and he kept tossing random ethical scenarios at me like this. Was super over the top about it too. The best was "So if I had terminal cancer and wanted more pain medicine so that I could kill myself, how would you respond?". I gave (what I remember to be) an appropriate answer about treating the pain but not giving a deadly amount but then he repeated multiple times about being insistant to get some extra medicine for the purpose of killing himself. Sure, I could hold my ground, but just the whole interaction was bizarre. Maybe I didn't handle it right b/c I didn't get in there, but to be honest after that I wouldn't have chosen their school anyway (plus it was a depressing campus, but that's another story).
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(University of Albany does not have a medical school)
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Upon reading the question my first thought, well it would be the spouse or parents/childrens choice if the pt didn't have their wishes down in writing.
Also could you just give them time to figure out a decision and give pros and cons to both choices and answer their questions/concerns.
If it were asked as if I were in the family I wouldn't know exactly what I'd do then...
Also could you just give them time to figure out a decision and give pros and cons to both choices and answer their questions/concerns.
If it were asked as if I were in the family I wouldn't know exactly what I'd do then...
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The med school in Albany, NY. There's only the one 😛
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SORRY GUYS LAST QUESTION I've been thinking this one over for about 2 days PLEASE HELP thank you so much
You enter a room to find your HIV patient very distraught because he's been told by a lay chaplain that he's going to hell and that his sickness is punishment for his lifestyle. What do you tell the patient, and how do you handle the lay chaplain?
My idea was to initially, ask the patient how he felt and ask him if there was anything immediately that I could do for him. I would also reaffirm what we can do to help the course of disease (given the limitations of his insurance, etc) and see what the next steps would be for him. (In the question, we are given this off-chance where he starts screaming that he will harm himself...in this situation, I guess I would ask him to take deep breaths, ask if he needed a break before we continue our discussion and then go seek someone - a therapist/psychiatrist - to evaluate if he needed to be monitored).
I would probably try to find another religious leader in his denomination that the hospital may be aware of to give him better support throughout the course of his disease, as well as various resources/support groups?
In terms of the lay chaplain, I would want to hold a discussion about how disease is sensitive. I'm not sure how I would approach the concept of how could he know if this is truly God's way of punishing? Things do happen - people don't disclose their illness to their partner, methods of protection don't work, etc.
I need help expanding and don't know if my thought process is correct
You enter a room to find your HIV patient very distraught because he's been told by a lay chaplain that he's going to hell and that his sickness is punishment for his lifestyle. What do you tell the patient, and how do you handle the lay chaplain?
My idea was to initially, ask the patient how he felt and ask him if there was anything immediately that I could do for him. I would also reaffirm what we can do to help the course of disease (given the limitations of his insurance, etc) and see what the next steps would be for him. (In the question, we are given this off-chance where he starts screaming that he will harm himself...in this situation, I guess I would ask him to take deep breaths, ask if he needed a break before we continue our discussion and then go seek someone - a therapist/psychiatrist - to evaluate if he needed to be monitored).
I would probably try to find another religious leader in his denomination that the hospital may be aware of to give him better support throughout the course of his disease, as well as various resources/support groups?
In terms of the lay chaplain, I would want to hold a discussion about how disease is sensitive. I'm not sure how I would approach the concept of how could he know if this is truly God's way of punishing? Things do happen - people don't disclose their illness to their partner, methods of protection don't work, etc.
I need help expanding and don't know if my thought process is correct
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What I was trying to get at is that something is not right because it's protocol, although something may be right and be protocol. I don't think we're in disagreement about the importance of consent in these matters. Most people would agree that the decision should be left up to the patient first, followed by those they left in charge of such matters. It's for this reason the question purposely muddies the water in this area. But the idea is that consent is not valuable and justified because it's protocol.
Consider a hypothetical situation in which protocol changes. Those in authority to make such changes decide that patients are too misinformed about medicine, and can't properly weight risk/reward. A new policy is put in place, call it "Doctors Know Best". What the doctor says goes, and explicit consent is not needed on an operation the doctor deems fit in many cases. They doctor knows best, after all.
I don't think you would endorse such a policy, given what you said about consent. But you cannot justify why it's wrong by appealing to protocol (which is pretty much the same as appealing to authority), because the protocol now puts doctors' decisions above patient decisions. It would have to be on other grounds, and I'm sure you could come up with many. Why, then, do you need the protocol? You don't need it to justify your ethical decisions unless you'd be willing to say that consent is no longer important, because protocol says otherwise. This is a scary idea indeed. You also cannot appeal to current protocol, because you would have to justify why one is better than the other, which necessarily involves stepping outside of its tenants.
In essence, I'm against appealing to protocol because it's created by people with no higher conception of goodness than you do. At least, not necessarily, by virtue of the fact they have the authority to make such decisions.
Now, an interesting point was brought up by @Raryn, who said our knowledge is limited in many circumstances, and for that reason we should trust those with more experience/knowledge in this area to make some ethical decisions. However, I don't think Raryn is saying we have limited moral knowledge (correct me if I'm wrong), and that those who design protocol have a better sense of what is morally correct. Rather, he's saying we have limited empirical knowledge. Laws, cost/benefit analyses, and relevant studies would count as empirical knowledge, for example. Because experts have greater empirical knowledge, it's acceptable to accept their decision. Not because they can weight the various factors better than you can, assuming both you and the experts are given the same relevant set of information needed to make a decision.
But in ethical questions like the one above, and ethical questions generally, the variables are reduced such that we have all the relevant pieces of empirical information (ideally, in any case). Think about trolley problems and you'll see what I mean. Of course, the nature of ethical questions in medicine necessarily introduces more possibilities for empirical concerns than trolley problems do. But ideally, the nature of the question is such that it spurs moral deliberation as much as possible, and keep the necessity of empirical knowledge to a minimum. That's not to say appealing to protocol is wrong in real-life situations, where our limited empirical knowledge is very relevant. But since idealized ethical questions try to mitigate these factors, we should treat them with their intended effect in mind, rather than try to exploit their limitations.
Edit: That was longer than I intended. Also I might have switched ideas halfway. Oh well- hopefully you get what I'm saying.
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Here is the thing, do you think a critical care md has the time to hash out all the minutiae of ethical decision making by himself? Do you think that all physicians are infallible ethical decision makers? That is the problem. This is the reason you appeal to protocol first, it is a rational method of making these decisions that society has decided upon. These standards, like the standard of care change over time, but that does not mean appealing to them first is a bad idea. The protocol is not some alternative reality protocol that you have created. It is based on the legal and ethical conception of consent and it exists for a reason. 99 percent of the time optimal resolution can be had just by relying upon the protocol. Plus if a protocol is wrong you should be actively working to correct the protocol rather then circumvent it. That protocol is being used on other patients , and the doctor who you will hand your patients off to will be using it as well. If it is a bad protocol you fix the protocol and then use it.
For the purpose of the argument you are adding extraneous information to the question that the original poster did not add. If the interview will ask a sloppy question I will give an answer that will take advantage of the holes in the question, if relying upon the DPOA is that I will do so.
Now to your each person is capable of making the morally correct decision. I can tell you by experience that this is a very dangerous standard to live by. Physicans training, expertise, experience and comfort levels vary in sticky situations. This leads to inconsistent decision making, coupled with decision making that may be illegal , or immoral at times. This is the reason you defer to the ethics consult, committee or people who are experienced in this sort of decision making. The last thing you want is a bunch of Maverick MDs calling ethical shots alone. These questions serve as a litmus test to see if the student is capable of realizing when they are in above their head, when they should reach out to more experienced people etc. When they should operate in a team and rely upon that team to reach the best decision for their patients.
TLDR: Everyone's expertise in ethical issues is varied, use protocol, and if it fails reach out to teams designated to solve such problems.
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Ethics are context sensitive. 40 years ago, the prevailing ethical paradigm *was* "doctor knows best", and it wasn't considered wrong. It evolved to our current valuation of patient autonomy, but that doesn't mean that the current valuation is objectively correct. Morals in general are an appeal to authority, so your entire point is somewhat misguided.
(Note: the actual philosophers will argue the point of natural ethics, but I think it's silly. They evolve based on your society, and while we obviously consider the current state of being superior to a past one, there's no way to measure that. And 20 years from now looking back we'll consider our now-current state of being to be superior to the one in 2017).
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Firstly, replying to @libertyyne:
One point in my longer post was that ethical questions in medicine are naturally sloppy, because there are many empirical concerns that are normally factored in in practice. Which is why I thought it was unnecessarily to go through 20 questions of loopholes, when the actual dilemma is plain from the beginning. Unless the point is to show how much you know about how actual practice is run.
No, I never said either of these things. It is not necessary to hash out all the minutiae or be infallible ethical decision makers. And I did say it's reasonable to use protocol in real world situations towards the end of my post. The point I was trying to make was that in ethical questions, we should be able to justify our decisions without appealing to protocol, and that protocol isn't necessarily "correct" in any transcendental sense. I was speaking primarily in terms of isolated, idealized cases, like what the OP presented.
What do you mean by "optimal resolution" and the idea that the protocol is wrong? How do you know a protocol is wrong? It certainly doesn't say so in the protocol. It sounds like you're using some other standard to judge the protocol itself. And I never said we shouldn't work to correct a faulty protocol. I'd be in support of this measure.
What extraneous information? I basically just took his question at face value, after clarifying some points in the beginning.
One point in my longer post was that ethical questions in medicine are naturally sloppy, because there are many empirical concerns that are normally factored in in practice. Which is why I thought it was unnecessarily to go through 20 questions of loopholes, when the actual dilemma is plain from the beginning. Unless the point is to show how much you know about how actual practice is run.
I definitely do not advocate people defying standards in the way you mentioned. There has to be standards in practice in institutions and law. But that doesn't mean certain people have special knowledge of what is morally correct, outside of empirical knowledge, which is really what you mean by knowledge gained by experience. If a situation comes up in real life where I feel unprepared to make a proper decision, I would refer to people with more experience or specialize in said area. This happens all the time. But that's different from an idealized ethical dilemma in a question, in which we have the relevant empirical information. In this case, I don't see why any person should have a more "correct" answer than any other, and its for that reason I advocated not appealing to protocol, but on your intuition and underlying reason.
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Secondly, replying to @Raryn:
The paradigm 40 years ago was why I used the example. And the point I was trying to make was what you're saying, that our current valuation isn't objectively correct. That's why I advocated against pointing to protocol to justify an ethical dilemma, but rather underlying reasons that fit your intuition. Although you could say intuition in general is largely socially constructed, I still think it's superior to pure protocol.
I think philosophy in general is moving away from objective truth, although many historically famous philosophers believed it. Then again, there were many that advocated a sort of relativism from the beginning as well (ex. Protagoras).
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This is the most on point answer in the thread.
If in an interview you find yourself responding to an ethics question with "I would obey the law" or "I would find out the hospital protocol". - you've basically flunked the question.
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I might be an outlier, but I start with the protocol and if they prod more I give the answer they are looking for. I have mostly had success with this since I am 3 for 3 in interviews where ethics questions were asked but who knows how much weight was given to those questions and n=1.
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I suppose I dont just say follow the protocol , rather I explain the application of the protocol, and the reasoning behind it. Point taken though.
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It's like -- "I'd get an ethics consult."
There's usually a order of succession for decision making.
There's also sometimes an "advanced directives" form that can help guide decision making. If your hospital is good -- they ask patient about DNR/DNI status before it gets to that point. Generally, I can see sudden trauma being an exception to getting this sorted out beforehand.
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Except DNR/DNI status has very little to do with the question at hand. That status only addresses the singular situation of what to do in event of a code. Very common answer to that question is "well yes, I'd like you to try to resuscitate me and give me a chance." Well great. You give them a chance, and patient ends up on the vent. Two days later, four days later, they're showing minimal signs of neurologic recovery. Now, unless the patient has a clear advanced directive addressing this situation, you have to ask the family what to do next.
You say great, just make every patient fill out a full advanced directive on admission. Well, that's much more of PITA than just getting the code status and frequently isn't practical. The one thing I *do* try to do on admission (if the patient is mentally with it) is clearly document who they would want to make decisions for them if they are incapacitated. It's not uncommon that the patient prefers their niece to their son (for example), and it gives you a bit more oomph later on if you asked the patient that and wrote it down later.
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