An End-of-Life Ethics Consult in the ICU: Who Has the Final Say- The Patient or the Family?

IF 9.5 1区医学 Q1 CRITICAL CARE MEDICINE Chest Pub Date : 2024-10-25 DOI:10.1016/j.chest.2024.10.028

Lindsay R Semler, Ellen M Robinson, M Cornelia Cremens, Fred Romain

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Abstract

A 72-year-old gentleman with metastatic pancreatic cancer was admitted to the ICU with increased oxygen demand and confusion, likely related to pulmonary metastases. In the presence of his son, the healthcare agent, and the team, the patient requested to be do-not-attempt-resuscitation and do-not-intubate (DNR/DNI) before losing decision-making capacity. When the patient's brother and another son heard of the code status change, they insisted on a return to Full Code. Although the youngest son (the healthcare agent) was present for the patient's request to be DNR/DNI, he declined to represent the patient's wishes and agreed with a return to Full Code. Numerous discussions over subsequent days revolved around the attempt to honor the patient's wishes in the setting of the surrogate's unwillingness or inability to make decisions in alignment with his father's wishes. This case reviews and analyzes the ethical options available to the clinical team in responding to requests for potentially inappropriate treatment at a patient's end of life, and explores the roles of relational autonomy, beneficence vs nonmaleficence, and holding the balance of clinicians' and ethicists' professional, legal, and ethical responsibilities.

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重症监护室中的生命终结伦理咨询：谁有最终决定权--患者还是家属？

一名患有转移性胰腺癌的 72 岁男性患者在入住重症监护病房时出现了氧需求增加和意识模糊的症状，这很可能与肺转移有关。在其儿子、医护人员和团队在场的情况下，患者要求在丧失决策能力之前不进行人工呼吸和不插管（DNR/DNI）。当患者的兄弟和另一个儿子听说代码状态发生变化时，他们坚持要求恢复到完全代码状态。尽管最小的儿子（医疗代理人）在患者要求 DNR/DNI 时在场，但他拒绝代表患者的意愿，并同意恢复完全代码。随后几天的多次讨论都围绕着在代理人不愿或无法按照其父亲的意愿做出决定的情况下如何尊重患者的意愿展开。本病例回顾并分析了临床团队在应对患者生命末期可能不适当的治疗请求时可供选择的伦理方案，并探讨了关系自主、受益与非受益的作用，以及临床医生和伦理学家在专业、法律和伦理责任之间的平衡。

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来源期刊

Chest 医学-呼吸系统

CiteScore

13.70

自引率

3.10%

发文量

3369

审稿时长

15 days

期刊介绍： At CHEST, our mission is to revolutionize patient care through the collaboration of multidisciplinary clinicians in the fields of pulmonary, critical care, and sleep medicine. We achieve this by publishing cutting-edge clinical research that addresses current challenges and brings forth future advancements. To enhance understanding in a rapidly evolving field, CHEST also features review articles, commentaries, and facilitates discussions on emerging controversies. We place great emphasis on scientific rigor, employing a rigorous peer review process, and ensuring all accepted content is published online within two weeks.