View source for WBR0329

{{WBRQuestion
|QuestionAuthor={{YD}} (Reviewed by Serge Korjian and {{Alison}})
|ExamType=USMLE Step 1
|MainCategory=Ethics
|SubCategory=General Principles
|MainCategory=Ethics
|SubCategory=General Principles
|MainCategory=Ethics
|SubCategory=General Principles
|MainCategory=Ethics
|MainCategory=Ethics
|MainCategory=Ethics
|SubCategory=General Principles
|MainCategory=Ethics
|SubCategory=General Principles
|MainCategory=Ethics
|SubCategory=General Principles
|MainCategory=Ethics
|SubCategory=General Principles
|MainCategory=Ethics
|MainCategory=Ethics
|SubCategory=General Principles
|Prompt=An unconscious 67-year-old man with no advance directive is brought to the emergency department by EMS. Following appropriate work-up, the patient is diagnosed with an ischemic stroke and is admitted for appropriate management. Several days later, the physician in charge informs the family that the patient is in a persistent vegetative state supported by machines. The patient has no attorney for healthcare and has no court-appointed legal guardian. When informed, the patient's family members start to discuss among themselves the possibility of taking the patient off life support. His wife states that her husband "would have wanted to stop life support right away". On the other hand, the patient's children and siblings argue that his wife's decision is not in his best interest. They all agree that based on previous decisions made by the patient, "he would do anything to stay alive". The family members ultimately fail to reach a unanimous decision. Which of the following is the most appropriate way to proceed with this patient's case?
|Explanation=The Patient Self-Determination Act of 1990 states that hospitals, nursing homes, health maintenance organizations, and hospices that participate in Medicare and Medicaid should inquire about advance directive and should incorporate advance directive into patients' medical records. Also, Patients should have the adequate amount of information about advance directive. 

Written advance directives are either a living will or a durable power of an attorney for healthcare. When unconscious patients with no advance directives are hospitalized, the patient's surrogate is his decision-maker for life-sustaining medical interventions. Surrogates should make decisions that conform to what the patient would want, based on written or oral advance care planning. If advance care planning is not available, the patient's desires may be assumed on the basis of the patient's social values, previous decisions, and beliefs, or on the basis of the patient's best interest if these values are not agreed upon. the following order of priority for health care surrogates must be taken into account:
1- Patient's guardian<br>
2- Patient's spouse<br>
3- Patient's adult son or daughter<br>
4- Patient's parent<br>
5- Patient's adult brother or sister<br>
6- Patient's adult grandchild or adult relative who is familiar with the patient and has shown care and concern for the patient <br>
7- Patient's close friend<br>
8- Patient's guardian of the estate<br>

At all times, physicians must be careful to make sure that the patient's surrogate makes decisions that are consistent with the patient's own values and his best interest. In case of conflict or difficult situations, hospital ethics committees may be useful to help patient families reach reasonable conclusions. In this scenario, the patient cannot make his own decisions, so the patient's wife is considered his health care surrogate. The physician must ensure that the spouse's decisions must conform to the patient's values and beliefs based on previous decisions made by the patient and his own set of values and beliefs. In the scenario above, other family members argue that the patient's wife might not have the patient's best interest in mind. Accordingly, the physician in charge may use the help of a hospital ethics committee to aid the family in reaching a conclusion.
|AnswerA=The physician in charge must adhere to the decision of the patient's wife. However, physicians must be careful to make sure that the patient's surrogate makes decisions that are consistent with the patient's own values and his best interest. In case of conflict or difficult situations, hospital ethics committees may be useful to help patient families reach reasonable conclusions. 
|AnswerAExp=The patient's wife comes first in priority in being the patient's health care surrogate.
|AnswerB=The physician in charge must adhere to the decision of the patient's adult children
|AnswerBExp=The decision of the patient's children is considered when the patient's wife is not present or is not a candidate to make decisions.
|AnswerC=The physician must ask the court of law to decide whether the patient should be off life support or not.
|AnswerCExp=There is no need at this point to request from the court of law to make decisions for or against life-sustaining medical interventions.
|AnswerD=The physician must adhere to the decision of the patient's primary care physician.
|AnswerDExp=Caring physicians of the patient have no role in deciding for or against life-sustaining medical interventions.
|AnswerE=The physician must ask the hospital ethics committee for help 
|AnswerEExp=In case of conflict or difficult situations, hospital ethics committees may be useful to help patient families reach reasonable conclusions.  In this scenario, other family members argue that the patient's wife might not have the patient's best interest in mind. Accordingly, the physician in charge may use the help of a hospital ethics committee to aid the family in reaching a conclusion.
|EducationalObjectives=A patient's spouse is considered the health care surrogate for adult patients who do not have any advance directive.
|References=Snyder L. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156(1 Pt 2):73-104.<br>First Aid 2014 page 60
|RightAnswer=A
|WBRKeyword=Life-sustaining, Intervention, Interventions, Life-sustaining intervention, Life-sustaining interventions, Life sustaining intervention, Life sustaining intervention, Life support,  Proxy, Stroke, Vegetative state, Ethics, Spouse, Advance directive, Advance, Directive, Healthcare proxy, Attorney for healthcare, Health care proxy, Attorney, Attorney for health care, Surrogate, Surrogates
|Approved=Yes
}}