Sharon M. posted a comment that I had informed Eva’s son and it was ultimately up to him. True that he was key in this process. He was the voice for Eva. If he chose, is everyone who cares for Eva bound by his decision? What if the harm of resuscitation outweighed the benefit? What if it is a different story and the patient was in an accident and is in a coma. The doctors think aggressive treatment can save her, return her to a functional life with quality (and who gets to decide that anyway)? The surrogate says, no, do not intubate. Whose decision should carry the weight? How would YOU decide?
What could I do? What should I do with Eva’s case?
We were taught certain key values in ethics classes:
Autonomy: Every person has the right to self determination. This would include the surrogate decision maker, like Eva’s son, acting on her behalf.
Beneficence: We are to act for the good of the patient
Non-Maleficence: “Primum no nocere” or First, do no harm
Justice: This calls for the fair distribution of scarce resources and fairness and equity in delivery of care (not a hallmark of the US Healthcare System)
Respect: Every person should be treated with dignity
Honesty and clarity: Informed consent comes from this concept.
There is a four box methodology for sorting through all this, which is copied from here
The Principles of Beneficence and Nonmaleficence
The Principle of Respect for Autonomy
|QUALITY OF LIFE
The Principles of beneficence and Nonmaleficence and Respect for Autonomy
The Principles of Justice and Fairness
Back when I first was a student and resident, we involved patients and families in discussions of code status. Usually we agreed. If we did not, we would continue to talk with patients and families and tell them if we thought the person was a “no code.” This process became more formalized in the places I practiced, but there still were still times when the patients and their families did not agree with us, the doctors. We talked and inevitably we agreed, always, in my practice, erring on the side of letting someone stay in the full resuscitation category.
Never before Eva had I reached this block. Take a look at the four boxes. What do you need to know in Eva’s case? How would you approach this? If it is totally Eva’s son’s right to decide, do I have an obligation to perform CPR and advanced life support measures, even if they go against what I think I took as a physician’s oath?
In all ethical crises, two or more values come into conflict. In this one it is where autonomy comes into conflict with beneficence/non-maleficence. Can you weigh in?