Case Study: An Alert and Incompetent Self The Irrelevance of Advance Directives

Abstract

A seventy-three-year-old woman with a history of emphysema and manic depression was admitted to the hospital with shortness of breath. She was treated with steroids but developed progressive respiratory failure and psychosis. She was intubated and transferred to the intensive care unit where she was found to have a blood clot in her lung. She was treated with a blood-thinning agent and had a major blood episode. She remained confused, presumably because of oxygen deprivation, infection, and chemical imbalance, though the staff could not rule out permanent brain damage. She was transferred to the chronic ventilator floor and with the consent of her primary care physician a feeding tube was placed and a tracheostomy was performed for long-term ventilator support. The critical care team hoped to wean her from the ventilator; the neurology consultant believed the patient might be able to be weaned successfully from the ventilator, but that it would take months at best. The patient remained confused but awake and alert. She interacted with staff and visitors and spent much of the day sitting up in a chair watching television. The psychiatrist who had followed her for manic depression found her cognitively impaired and incompetent for decisionmaking. Although the patient was widowed and without children or other living relatives, two close friends who said they had known her for fifty years spoke on her behalf. They were not legally designated proxies, but held and had witnessed the patient's living will, which the patient had executed twice, most recently five years earlier. The will indicated that the patient did not want to be kept alive by life-support technology if she had no reasonable expectation for recovery from extreme physical or mental disability. On the basis of their history with the patient and this will, the patient's friends and her primary care physician requested that she be removed from the ventilator. The critical care physician and nursing staff objected. The friends wrote a letter to the ethics committee explaining that this woman was an extremely independent-minded person, who would have hated being kept alive in this dependent condition. The patient's primary care physician who had known her for seven years supported this view. The critical care staff, however, were reluctant to have the tracheostomy tube removed because the patient appeared to be comfortable and gave no indication that she wished to be withdrawn from life support. When asked whether she wanted to be removed from life support she would indicate no. The patient's friends and primary care physician, however, believed she was too confused to understand the question. Citing the psychiatrist's report, they argued that she was incompetent to make this decision. The hospital's ethics committee was consulted and eventually supported the critical care team's decision to defer withdrawal of life-support while continuing to evaluate the patient's decisionmaking capacity and wishes. Committee members were influenced by the critical care physician's opinion that the patient was showing signs of improved cognitive function. They suggested that if the primary care physician remained committed to withdrawing life support immediately, he should arrange a transfer of the patient to another hospital. The physician had the patient transferred to another hospital where a physician indicated willingness to comply with the wishes of the two friends. On the day of the transfer the patient and nursing staff cried. The patient was transferred to the other hospital. The ethics committee was consulted and neurologic and psychiatric evaluations were ordered. The psychiatrist found the patient incompetent and the neurologist thought she had suffered permanent brain damage. The ventilator was removed and she died a week later. commentary Existing legal, policy, and ethical analyses fail to delineate clearly the range of permissible decisions on life-sustaining treatment for conscious incompetent patients. …