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

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.