Researching Law Volume 30, Number 2 - Flipbook - Page 6
R ESEA RC HI N G L AW
The goal of these
advance-care planning
conversations should
not be to document
instructions or draft
better scripts for
surrogates to follow,
but to brainstorm how
to improvise or cope
when the situation
is changing and
uncertain.
decisions inconsistent with
the patient’s wishes or best
interest, exacerbate the patient’s
suffering, or create havoc and
conflict among loved ones.
The most important proactive
action one can take, according
to Shapiro, is to weigh the
qualifications and trade-offs
in the job description of an
effective surrogate, find a
trusted individual who fits
the bill, ensure that he or
she is willing and up to the
task, document the choice
in an advance directive, and
begin or continue a lifelong conversation with the
surrogate. In most jurisdictions,
completing a directive that
names a health care surrogate
requires neither lawyers nor
notaries and forms are available
for free in hospitals and online.
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VOL 3 0 | N O 2 | FALL 2 019
Advance-Care Planning
In making medical decisions
on behalf of a patient, the
surrogate is asked to go beyond
following instructions to ask
questions, analyze complex
information, draw inferences,
and forge consensus. In
Shapiro’s observations, most
loved ones could have been
better prepared for these
responsibilities.
Many resources are available
to prepare would-be patients,
surrogates, and other loved
ones in thinking and talking
about expectations, goals,
values, trade-offs, priorities, and
fears. Questionnaires, videos,
workshops, and other stimulus
materials are available online
and in various forums from
doctors’ or lawyers’ offices to
senior or community centers.
The goal of these advance-care
planning conversations should
not be to document instructions
or draft better scripts for
surrogates to follow, but to
brainstorm how to improvise
or cope when the situation
is changing and uncertain.
Shapiro’s findings indicate
that conversations about the
decision-making process and
criteria are at least as helpful to
surrogates as are those about
specific desired outcomes,
which are likely to change or
be contingent on circumstances
that cannot be anticipated.
Surrogates are often tasked
with making decisions for
patients with little forethought
or preparation. Difficult as they
may be, ongoing conversations
help prepare loved ones before
it is too late.
The ABF is pleased to reprint chapter one of
Speaking for the Dying: Life-and-Death Decisions in Intensive Care
Holding Life and Death
in Their Hands
It is 6 A.M. The critical care resident
checks on one of his patients before
morning rounds and encounters ten
angry family members encircling
the unresponsive patient’s bed, livid
that he had been intubated (had
a breathing tube inserted into his
airway) and attached to a ventilator in
the middle of the night. The patient,
a seventy-six-year-old white man
and former purchasing agent, had
been admitted to the hospital for
a relatively minor stent (drainage
tube) procedure and to explore his
eligibility for a liver transplant. He
had previously designated his wife
power of attorney for health care and
documented that he did not want to
be resuscitated or intubated.
The previous day, tests had revealed
that the patient had liver cancer
and would probably not be eligible
for a transplant. Late that night
the patient experienced breathing
difficulties, and the medical team
asked for his consent to be intubated
and placed on a ventilator. At 3:25
A.M. the patient, alone in his room
in the intensive care unit (ICU), had
consented.
Two hours after the hostile encounter
in the patient’s room, the critical
care team—an attending physician,
fellow, and two residents—arrived
for morning rounds. As he examined
the patient, the attending physician
spoke to the assembled family.
CRITICAL CARE ATTENDING:
I’m going to look at his heart and
lungs, and then I know you have
concerns about the vent [ventilator].
WIFE: Pull the plug.
DAUGHTER-IN-LAW: This is not
what he would have wanted.
CRITICAL CARE ATTENDING:
Would he feel differently if he was
able to potentially get a transplant?
DAUGHTER-IN-LAW: No.
CRITICAL CARE ATTENDING:
If the cancer is confined to his liver,
they wouldn’t rule him out as a
transplant candidate. It’s a long shot,
I’ll be honest. But they haven’t ruled
him out yet.
WIFE: I thought they found fluid in
his abdomen and so he can’t get a
transplant.
told the nurses last night that he
wanted to be intubated, and in
effect retracted his living will. But
sometimes when people are in
distress, they’ll make decisions
differently. You don’t think this is what
he wanted?
WIFE, DAUGHTER-IN-LAW,
DAUGHTER, AND TWO SONS:
[In unison] No.
CRITICAL CARE ATTENDING:
They haven’t told us that he’s
definitely not a candidate.
DAUGHTER-IN-LAW: He talked
about this at length with me in the
last three months. He told me in
detail what he wanted. It’s not this.
WIFE: Just pull the damn plug!
WIFE: I think he was just frightened.
CRITICAL CARE ATTENDING:
See, we’re in a bit of a bind. He
DAUGHTER-IN-LAW: Yes, I think
he was scared. He thought he was
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