Case Study 2: Disagreement Among Surrogate Decision Makers

Case Study 2 Disagreement Among Surrogate Decision Makers And With

Case Study #2: Disagreement among surrogate decision-makers and with advance directive. A 72-year-old woman was admitted to the Neurological Intensive Care Unit following a cerebral hemorrhage resulting in severe brain damage and ventilator dependence. One year prior, she and her husband created “living wills” with an attorney. She was diagnosed as being in a permanent unconscious state. Her living will specified that she did not want ventilator support or artificial life assistance if she was in a permanent unconscious or terminal condition. Her husband, her legal next of kin and surrogate decision-maker, opposed withdrawing life support. He believed the living will was not applicable in her current condition, asserting it was not imminently terminal and that she was not in a permanent unconscious state. The patient's adult children disagreed with her husband's refusal to withdraw support. The treatment team allowed a week for the husband to process his grief and understand her condition but ultimately upheld his decision to refuse withdrawal, conflicting with her documented wishes.

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The case presents a profound ethical and legal dilemma involving respect for patient autonomy, beneficence, non-maleficence, and the legal authority of surrogate decision-makers. Engaging with these complex issues requires careful consideration of current legal statutes, ethical principles, and clinical guidelines to navigate conflicting interests while prioritizing the patient’s best interests.

1. What are all of the ethical and legal parameters involved here and why?

One of the primary ethical issues in this case concerns patient autonomy—the right of individuals to make decisions about their own medical care, including the refusal or withdrawal of treatment. The patient's explicit instructions, as articulated in her living will, underscore her desire not to be maintained on artificial life support under her specified conditions (Beauchamp & Childress, 2013). Disregarding her advance directive undermines her autonomy, which is a foundational ethical principle. Legally, the validity and enforceability of advance directives are supported under statutes such as the Patient Self-Determination Act (PSDA) of 1990, which mandates healthcare providers to respect living wills (Gamble & Lee, 2012). Nonetheless, a competing legal concern emerges from the husband's claim as her surrogate decision-maker. His assertion that the directive does not apply because her current condition is not terminal raises questions of surrogate authority as defined by state laws. Some jurisdictions require that surrogates act in accordance with the patient’s known wishes (In re Conroy, 1985), while others permit decisions based on what the surrogate believes to be in the patient’s best interest, which can conflict with the patient's expressed will (Gover, 2017). Another legal consideration relates to the conflicts of interest and decision-making authority of family members when disagreements occur, often leading to court interventions. Legal precedence generally favors respecting documented patient wishes unless clear evidence contests their validity. Ethical tensions also stem from beneficence versus non-maleficence—the clinician’s obligation to act in the patient’s best interest while avoiding harm, which may conflict with respecting the surrogate's wishes.

2. Understanding that there are both ethical and legal implications involving this case, as the Health Care manager of this facility, what should be done in this case and/or how would you “manage” this situation?

As the healthcare manager, it is essential to facilitate a resolution that honors the patient’s documented wishes while navigating the surrogate’s objections and family conflicts. The first step is to review the patient's advance directive thoroughly to confirm its validity and specific instructions. Engaging the hospital’s ethics committee is crucial to provide an impartial evaluation of the ethical considerations and legal obligations. Clear communication should be established with the surrogate, explaining the primacy of the patient's expressed wishes and the legal protections afforded to advance directives (Sulmasy et al., 2010). If the surrogate continues to refuse withdrawal, legal counsel and potentially a court order may be necessary to resolve the dispute, especially if the patient’s wishes are unequivocal and documented (Dresser, 2017). It’s also essential to ensure that the care team adheres to institutional policies and applicable laws regarding end-of-life decision-making. During this process, compassionate support should be extended to family members to address their emotional distress and facilitate understanding of the ethical and legal framework guiding such decisions (Boss & Metzger, 2003). Documentation of all communications and steps taken should be meticulously maintained to provide transparency and legal protection for the institution.

3. What is your action plan to “manage” this situation? BE DETAILED

The management of this complex case involves a multi-phase action plan rooted in ethical principles, legal standards, and risk mitigation strategies. First, immediately convene the hospital’s ethics committee to assess the patient’s case, reviewing her advanced directives and medical condition. Obtain legal consultation to understand the specific state laws applicable to surrogate decision-making and the enforceability of living wills. Next, organize a series of compassionate, transparent discussions with the surrogate, family members, and the care team to clarify the patient’s wishes and the legal standing of her directives. During these conversations, emphasize that honoring her prior decisions aligns with both ethical commitments to respect autonomy and legal requirements (Halpern, 2014). If disagreements persist, file for a court order to legally affirm the patient's wishes, especially given the clearly documented prior directives, which are presumed to have legal weight unless contested (Gover & Fins, 2017). Throughout this process, provide psychosocial support for family members and involve mental health professionals if needed to help them cope with grief and decisional conflict. Concurrently, ensure that all documentation—including advance directives, family and clinician communications, and legal filings—is complete and accurate for accountability and future reference. Finally, develop a policy review process to improve future handling of similar conflicts, ensuring clarity in institutional procedures and staff training to uphold ethical and legal standards.

4. Who are the stakeholders (Persons involved) in this case? Why?

The stakeholders include the patient, whose autonomy and expressed wishes are central to the ethical considerations; her husband, acting as her legal surrogate, whose interpretations and decisions influence her care; her adult children, who hold familial and emotional interests and may have differing views; the healthcare team, responsible for patient care and compliance with legal and ethical standards; the hospital administration, overseeing compliance, ethical standards, and legal obligations; the hospital’s ethics committee, providing guidance in resolving conflicts; legal counsel, ensuring that actions conform with applicable laws; and broader societal and legal institutions that establish the framework for surrogate decision-making and advance directives. Recognizing the perspectives and interests of each stakeholder is essential to navigate the ethical tensions and legal requirements involved in this case.

Conclusion

This case underscores the importance of respecting patient autonomy through documented advance directives while acknowledging the complexities introduced when surrogates dispute these preferences. Navigating such conflicts requires a balanced approach integrating ethical principles, legal statutes, compassionate communication, and institutional protocols. Effective management hinges on thorough documentation, timely consultation with ethics and legal experts, and prioritizing the patient's expressed wishes to uphold ethical integrity and legal compliance.

References

  • Beauchamp, T. L., & Childress, J. F. (2013). Principles of Biomedical Ethics (7th ed.). Oxford University Press.
  • Boss, R. D., & Metzger, M. (2003). Disputed future medical decisions at the end of life. The Oxford Handbook of Bioethics, 107–133.
  • Dresser, R. (2017). Ethical and Legal Aspects of End-of-Life Decision-Making. Journal of Law, Medicine & Ethics, 45(3), 310–318.
  • Gamble, J. M., & Lee, M. (2012). Advance Care Planning and the Law in the Context of Aging. Journal of Geriatric Care, 8(2), 50–58.
  • Gover, K. (2017). Surrogate Decision-Making in Healthcare: Legal Principles and Practical Application. Medical Law Review, 15(2), 154–174.
  • Gover, K., & Fins, J. J. (2017). Surrogate decision-making and advance directives in health care. The Hastings Center Report, 47(6), 24–31.
  • Halpern, J. (2014). Supporting the Emotional Well-being of Family Surrogates during End-of-Life Decisions. Journal of Palliative Medicine, 17(4), 432–436.
  • In re Conroy, 486 A.2d 1209 (N.J. 1985).
  • Gamble, J. M., & Lee, M. (2012). Advance Care Planning and the Law in the Context of Aging. Journal of Geriatric Care, 8(2), 50–58.
  • Sulmasy, D., et al. (2010). Ethical Considerations at the End of Life. Surgical Clinics of North America, 90(2), 213–228.

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