Best interest’ can be tricky when patient is unknown
Withdrawing futile care difficult decision
Questions surrounding resuscitation and other heroic measures, surrogacy, and withdrawal of futile care are complicated enough, but they can be even more complex when the patient is unidentified.
These "John or Jane Does" can require special attention from hospital ethics committees because they may require physicians and hospitals to make judgments call about what is in the best interest of the patient.
"The John and Jane Doe patients can be confounding for physicians on an ethical basis, because their desires and wishes are unknown, and we may not be able to locate a surrogate to speak for them," says Mark Wesselman, MD, a hospitalist with Lovelace Health System in Albuquerque, NM, and a member of the ethics committee of the Society of Hospital Medicine (formerly the National Association of Inpatient Physicians).
When clinical decisions need to be made, what is the best approach? When might it be appropriate to withhold or withdraw care?
The lack of an identity is not necessarily a problem in the first hours a patient is brought in to an emergency department with a life-threatening illness or injury, Wesselman says. At that point, the general rule of thumb is to err on the side of saving the patient and taking the steps necessary to do so.
Putting a name to the face
It is uncommon for patients to never be identified, though the search might take several hours or days, Wesselman reports.
"We usually can figure out who they are," he says. "Usually within 48 hours, we have a name for them.
"But that doesn’t always change a lot — it just gives them a name. If someone lacks the capacity to make decisions for himself, even if he has been identified, then we have to find a surrogate."
States generally establish who a patient’s surrogate may be, determined by the patient’s age (minor or adult) and familial relationships (spouse, life partner, parents, children, siblings), or close friends.
Usually, the search for a surrogate turns up a relative who acts as the patient’s advocate in making major health care decisions, but sometimes, that’s not the case.
Sometimes a family member is located, but will be reluctant to act on behalf of the patient because the patient may have been estranged from the family.
Wesselman notes that in cases like those, an explanation of the patient’s condition and the need for someone to make a decision on continuation or discontinuation of care is all it takes for the surrogate to agree to act. "Rarely, a surrogate will bow out; and in those cases, we just have to keep looking for another one," he says.
No surrogate — who decides?
Most relevant to an ethical analysis of deciding on potentially futile care or the withdrawal of care, Wesselman says, is determining what the wishes of the patient might be. This dilemma is only more intense when hospitalists are faced with a comatose, critically ill patient whose illness is so profound that some medical interventions are questionable or futile.
Occasionally, a patient — identified or not — has no surrogate who can be located by the hospital, and the patient’s wishes are not known. When the question arises as to whether care is futile and should be discontinued, hospital policy, the ethics committee, and community standards step in to decide what steps are in the patient’s best interest.
"When you are talking about withdrawal of care and medical futility, most hospitals have policies in place, such as having two physicians who are caring for the patient be in agreement that the patient’s medical condition is such that there is no meaningful chance for recovery or the care is futile, and then notifying risk management," Wesselman says.
An ethics committee or other panel that includes representatives of the institution, physicians, clergy, risk management and legal, and perhaps a member of the community (to give an objective lay voice to the group) may convene, and the treating physicians present the patient’s condition, their opinion on his chances of recovery, and what their course of action would be.
"Then we ask ourselves, What would a reasonable person in our community think about that? Is [withdrawing care] a reasonable choice?’" Wesselman says. "And then we say yes’ or no.’"
It’s a decision made with the patient’s best interest in mind, he adds, but involves a risk. "You’re putting your own values in there. How do you define best interest’? The goal is to preserve life, but I think a meaningful life."
- Mark Wesselman, MD, Hospitalist, Lovelace Health System, Albuquerque, NM; Member, Society of Hospital Medicine Ethics Committee. Phone: (505) 262-7000.