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Commentary
Published online by Cambridge University Press: 12 April 2004
Extract
Like some ethical dilemmas, this question has an obvious answer that may not be right. On first reflection, it seems entirely unreasonable and inappropriate to expect staff members to withhold supportive care. Legally, a designated surrogate has the authority to refuse pain medication on the patient's behalf, but is it ethically defensible? A patient lacking decisionmaking capacity is crying out in pain; can we really imagine just closing the door? What do we say to other patients, visitors, and staff members, such as physicians, nurses, housekeepers, and dietary workers, who might hear the patient? Do we place a sign on the door, one noting that the surrogate has refused, on behalf of the patient, to authorize the administration of pain medication and that the hospital or nursing home must comply with the surrogate's decision?
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- ETHICS COMMITTEES AT WORK
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Like some ethical dilemmas, this question has an obvious answer that may not be right. On first reflection, it seems entirely unreasonable and inappropriate to expect staff members to withhold supportive care. Legally, a designated surrogate has the authority to refuse pain medication on the patient's behalf, but is it ethically defensible? A patient lacking decisionmaking capacity is crying out in pain; can we really imagine just closing the door? What do we say to other patients, visitors, and staff members, such as physicians, nurses, housekeepers, and dietary workers, who might hear the patient? Do we place a sign on the door, one noting that the surrogate has refused, on behalf of the patient, to authorize the administration of pain medication and that the hospital or nursing home must comply with the surrogate's decision?
Important Considerations
Before suggesting some options for addressing this dilemma, we should acknowledge that there are legitimate differences in treatment preferences among patients, their families, and staff members. Healthcare professionals often unconsciously assume that the patient shares their values and, by extension, so do the patient's family and surrogate decisionmakers. Innumerable studies have found, however, that values and attitudes about healthcare are highly variable, particularly among different cultures, so we should remind ourselves that, although the rationale for pain relief may be self-evident to us, perhaps others do not share it.
Autonomy is a widely accepted ethical principle. Respect for the patient's right of self-determination regarding treatment and nontreatment options does not mean that we support the principle only when the decision of a patient or patient surrogate agrees with our own personal preference, regardless of how compelling it may be to us.
In this case, let us assume that the patient (a) is terminally ill, (b) recently consented to forgo life-sustaining treatment, (c) now lacks decisionmaking capacity, (d) is experiencing severe pain, and (e) has clearly designated someone to make decisions on her behalf. Let us also assume that her physician has recommended that morphine be given as an analgesic, but her surrogate has refused to give permission because it may depress the patient's respirations and make the patient less clear minded should she recover her decisionmaking capacity. As a second scenario, the same situation exists, but the surrogate has withheld consent for cultural reasons that are difficult to discern and understand. For a final scenario, the patient is a child, and both parents are unwilling to consent because they object to any intervention that might hasten death.
Possible Options
It is impractical to anticipate every reason or set of circumstances leading to disagreement between a patient's surrogate and healthcare professionals. Therefore, an organization's policy on forgoing life-sustaining treatment could contain a section, “Consultation in the Event of a Disagreement,” that provides generic guidance. Among the subheadings of this section might be brief paragraphs such as the following:
a. Role of the Ethics Committee. In the event of an unresolved disagreement between the patient, the patient's family, the designated decision maker(s), or members of the healthcare team over the decision of whether to forgo life sustaining treatment or supportive care, consultation with the ethics committee is recommended.
b. Role of the Risk Management and Legal Services. If consultation with the ethics committee does not resolve the conflict, then it shall be determined by the physician in consultation with the risk management department, which will consult with legal counsel, whether the case shall be brought to court.1
Rubin SB. Template Foregoing Life Sustaining Treatment Policy. Berkeley, Calif.: The Ethics Practice; 2002.
This approach will not be appropriate for every institution. Some organizations have ethics consultation services rather than ethics committees. In either case, consultation could be stipulated as required instead of being optional. Other organizations may not specify a role for the risk manager or risk management department. Similarly, the use of legal counsel and the judicial system can vary from one institution to another.
Forgoing life-sustaining treatment is difficult for healthcare professionals, as well as for patients and their families. By recognizing the surrogate's pivotal role when the patient lacks decisionmaking capacity, anticipating areas of disagreement, and developing options for resolution, the organization will demonstrate sensitivity to the needs and expectations of all participants in decisions near the end of life.
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