A 68-year-old Man Is Hospitalized With Acute Stroke

Ethics Case: 68-year-old man is hospitalized with acute stroke after collapsing on the golf course. Upon admission, patient was treated with TPA. His stroke subsequently became hemorrhagic, requiring emergent craniotomy. The patient never regained consciousness. After two weeks, his wife consented for tracheostomy and gastrostomy tube insertion. One month after admission, he remains unresponsive. He has non-purposeful movements of his left side. He does not follow commands. His pupils are equal but unresponsive to light. The ICU nurse has requested an ethics consult because she believes continued life sustaining treatment is futile. His wife still believes he will recover and is requesting that “everything be done.” Who should decide when treatment is futile?

Case Discussion

Nurse: “I took care of this patient when he was first admitted but did not see him again until these past few days. If anything, he looks worse now. I think it is wrong to keep him hooked up to the ventilator with no real hope that he will ever wake up or go home.”

Neurologist: “This patient has no realistic chance of regaining consciousness, but he does not meet the criteria for brain death. I believe removing life-sustaining treatment and letting the patient die would be the best course of action at this point, but part of my concern in doing this against his wife’s wishes is the fact that I administered the TPA, which may have lead to the complication of converting this to a hemorrhagic stroke, and I am concerned the wife might take legal action if I cross her.”

Patient’s Wife: “ As long as my husband is still alive, I’m just happy to be with him. At least we are still together. I am still hoping that he will be able to get off the breathing machine, get better, and go home again. I believe in whatever God wants for him. If God were ready for him, he would take him. I know he wouldn’t want to live like this permanently, but I’m not ready to say it’s enough because there is just never enough time. Maybe death is worse than this.”

Patient’s Daughter (the only other involved family member): “Three months ago, I had a discussion with my dad regarding his wishes and values. He told me at that time that quality of life for him was being with his grandchildren, going on long walks with my mom, golfing with his buddies, and tinkering around in the garage. If he could no longer do those things, then life for him would not be worth living. I know he would not want to be kept alive on machines, but I am just trying to support my mom because I think it has to be her decision.”

Ethical Case Analysis: When conducting an ethics consultation, there are various formats that can be followed. The most universally used approach is based on the Jonsen’s “four-box approach”: medical indications, patient preference, quality of life, and contextual features. Following is my analysis of this case using this model:

1. Medical Indications: This patient is permanently unconscious with no realistic chance of regaining consciousness. He will likely be permanently dependant on a ventilator as multiple attempts to wean him have been unsuccessful, and his weaning parameters have shown no sign of improvement. Obviously, he will also be permanently feeding-tube dependant. With continued treatment, he could survive for months to years in this state, likely requiring permanent placement in a long-term care facility. If he is extubated, he will most likely die within hours to days.
2. Patient Preference: The patient does not have an advance directive. The only information we have regarding his wishes is his conversation he had with his daughter three months prior to admission. At that time, he clearly defined what quality of life is to him: being with his grandchildren, golfing, walking, and working in his garage. Beyond those statements, we have no way of knowing what the patient’s preferences would be regarding his current treatment decisions. Would he want to be maintained on life-sustaining treatment with no reasonable chance of recovery? When we are trying to ascertain what the patient’s preferences are regarding treatment once they have lost decision-making capacity, we rely on a variety of sources. The source that carries the most weight is a written advance directive. In cases where the patient has no advance directive such as this one, the second source is verbal statements made to someone on the treating team, usually a physician or nurse. The final source is prior conversations with friends or family in which a patient may have discussed their preferences. In this case, we have no specific directive from the patient. We therefore must base our decision-making on “Quality of Life” factors in the next section.
3. Quality of Life: In each case, we must prognosticate the best possible outcome we will be able to achieve, the likelihood of achieving it, and the burden of treatment that must be endured in order to achieve our goal. We must then determine whether that outcome and the burden of treatment are acceptable to the patient. If we have statements from the patient regarding their preferences, our decisions must be guided by those stated wishes. If we have no statements regarding the patient’s preferences, then we must try infer their preferences based on what we know of the patient’s values. This is when the “substituted judgment” of a surrogate decision maker becomes vital. It is always best to ask, “If your loved one could speak to us right now, what do you think he or she would tell us they want?” In this case, both the daughter and wife confirmed that the patient “would not want to live like this.” We must conclude that the most likely outcome in this case — maintaining the patient in a permanently unconsciousness state — would not be consistent with the patient’s stated wishes and lifelong values.
4. Contextual Features: This includes other interested parties who might influence decision making (other family members or staff who disagree), legal implications, financial/economic factors, religious or cultural factors, resource allocation, public health issues, etc. In this case, the patient was insured, and his wife was financially secure. She did hold some religious beliefs that likely impacted her decision-making. It is unclear whether the patient shares his wife’s particular religious beliefs. Another feature in this case might be the physician’s concern of medical error and risk of legal liability with a bad outcome. These concerns certainly impact physicians’ clinical decision-making, but, ultimately, physicians must pursue the decision they think is best for the patient and disclose any medical error or adverse outcomes from treatments rendered.

Summary and Recommendations: This case illustrates the issue of determining medical futility. Medical ethicists have not been able to arrive at a universally accepted definition of medical futility. Many have proposed a quantitative definition, such as treatment having a less than 5 percent or less than 1 percent chance of providing benefit. The difficulty is that we cannot always agree on a definite cutoff, and, in addition, we don’t always have specific predictive prognostication in a given case. Others have proposed qualitative definitions with terms such as “no realistic chance of benefiting the patient,” but how do we define “realistic”? Who decides when treatment has reached the point of futility, the doctors, or the patient/family?

When the patient has lost decision-making capacity and has not designated a surrogate decision-maker via an advance directive, the treating physician(s) must then identify the most ethically appropriate decision-maker. When there are multiple individuals involved, this can be difficult. Helping to identify the most appropriate surrogate often becomes an important component of the ethics consultation process. Patients clearly have the right to refuse treatment, but do they always have the right to demand treatment? Most medical ethicists support the position that physicians are not obligated to provide futile treatment. Most, if not all, hospitals in California have some form of medical futility policy that supports the position that the surrogate’s primacy is not always absolute.

In this case, the doctor and nurse believe treatment is futile. Discontinuing life sustaining treatment and allowing a peaceful death would seem most consistent with the patient’s previously stated wishes and values. The treating team would need to help the patient’s wife follow through on what she believes her husband would want, not what she wants. She would need grief support from a chaplain, minister, or social worker. Reasonable accommodation could be made to allow her sufficient time to prepare for her husband’s death. This generally means waiting 2–3 days to withdraw life support and make sure the family is sufficiently prepared for the terminal extubation.

Once we can no longer meet the goal of restoring our patient’s health and quality of life, our goal must shift to facilitating a peaceful death. In doing so, we will have successfully accomplished our task of seeing our patients through the final stage of their lives.