Palliative Care and End of Life Issues: Fellow Case Report Poster - Palliative Care |

Surrogate Decision Making With Possible Secondary Gain FREE TO VIEW

Fatima Wong, DO; Faisal Siddiqui, MD
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Virginia Tech Carilion Clinic, Roanoke, VA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):944A. doi:10.1016/j.chest.2016.08.1046
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SESSION TITLE: Fellow Case Report Poster - Palliative Care

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Critical care physicians frequently engage in end of life discussions which are considered easier when a patient has an advance directive, a legal document addressing health care decisions and/or appointing a specific designated agent to perform such decisions if deemed incapacitated. In the intensive care unit (ICU),most patients are often incapable of making decisions and must rely on surrogate decision makers. Most states have implemented laws with hierarchy of surrogate decision makers. However, in an event when there is suspicion of acute toxic poisoning, no states except Texas, have legislations to assist physicians in making medical treatment decisions.

CASE PRESENTATION: A 78 year old female patient with dementia was admitted to an ICU for acute encephalopathy due to ethylene glycol toxicity. Her hospital course was complicated by the development of generalized myoclonic seizure activity. A continuous electroencephalogram later demonstrated that she had nonconvulsive epileptic activity which lasted for several days despite administration of several antiepilectic agents.The local authorities as well as the Adult Protective Services were notified for concerns of intentional poisoning since there were questions regarding access to the toxin. The patient did not have a prepared advance directive and her default decision maker was her son whom she lived with. The medical team was informed by patient's sisters that she had expressed previously not wanting to be placed on artificial life support. Several family discussions were held with the patient's son regarding her prognosis and previous wishes. However, he decided to continue with pursuing aggressive treatment. However, the ICU team members were concerned for the surrogate making decisions with secondary gain since he may be under investigation for possible attempted murder. The case was brought to the attention of the Ethics Committee with recomendations that under Virginia state law, the health care team was obligated to acquiesce with the decisions of the surrogate.

DISCUSSION: This case highlights the dilemma faced by critical care physicians frequently when faced with ethical dilemma of doing no harm differs from those of the surrogate decision makers. However, the situation is complicated when there is presumed secondary gain. Unfortunately, patients often do not have a previously prepared advance directive to help ensure that medical care is executed with their best interest instead of third party.

CONCLUSIONS: Such ethical cases should be presented to help bring awareness to these situations.

Reference #1: Fritch J, Petronio S, Helft PR, Torke A. Making Decisions for Hospitalized Older Adults: Ethical Factors Considered by Family Surrogates. Journal of Clinical Ethics. 2013; 24(2): 125-134.

Reference #2: Rid A, Wendler D. Treatment Decision Making for Incapacitated Patients: Is Development and Use of a Patient Preference Predictor Feasible? Journal of Medicine and Philosophy. February 20, 2014; 39: 130-152.

DISCLOSURE: The following authors have nothing to disclose: Fatima Wong, Faisal Siddiqui

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