From legal and ethical points of view, if a patient is competent to make a decision, the opinion of members of his family is irrelevant. The principle of autonomy, given by the Fourteenth Amendment to the U.S. Constitution, recognizes the right of an individual to make his/her own decisions concerning medical care. However, considering that the patient suffered serious brain damage but is not currently meeting the criteria for complete brain death, it is very likely that the patient is in the comatose state. Hence, the patient has no capability of making his/her own decisions concerning health care.
Analysis of Medical Care Issues
The absences of consciousness, respiratory, and cardiac functions are three conventional clinical markers for death. However, nowadays, modern technologies can maintain respiratory and cardiac functions for an indefinite period of time. Before the era of mechanical ventilation, any significant brain damage inevitably and promptly resulted in cessation of cardiac and respiratory function (Wijdicks, 2011). Prolonged comatose state, even when a patient is not dying, has overwhelmingly pressing effect on consideration about whether such radical medical intervention is futile and onerous. There is also a concern that continuing medical intervention may be a dishonor to the patient. It obviously causes tangible distress to relatives and sometimes to the medical personnel who see that their skills and time, as well as valuable medical resources, are used in the pursuit of futile goals. Therefore, in case if the attending physician has reasonably concluded that the patient’s brain condition is incurable and irreversible, the decision to withdraw the mechanical support device is a permissible course of action, regardless of whether the patient is acknowledged “brain dead”.
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Analysis of Legal Issues
In case if the attending physician of the patient determines that a patient is legally incompetent to make a decision concerning his/her further medical care, a person empowered to act on the patient’s behalf (a legal representative, next-of-kin, or legal guardian appointed by the court) has the right to make such decision. The first step for an administrator of a hospital is to establish whether the patient made any written health care legal advance directives, such as a living will or a durable power of attorney. In case of availability of the living will, the administrator is legally obligated to follow all the directions written in the will. In case of presence of the durable power of attorney, all decisions about the patient’s health care should be made only by a trusted representative of a patient. In case if there are no advanced directives or a will, a next-of-kin has the right of making medical choices on behalf of the patient (according to the order of precedence in the U.S.) (Pozgar, 2011). This authorized person should have all the information that is necessary to form an intelligent judgment for the patient’s benefit. In case of brain damage, the person has to know under what conditions the patient can be acknowledged dead. Many U.S. states have adopted the Uniform Determination of Death Act. According to this Act, a patient can be determined dead in two cases: firstly, in case of irrevocable stoppage of respiratory functions and absence of heartbeat or pulse; secondly, in case of irrevocable cessation of the brain stem and cerebral functions (Wijdicks, 2011). All this information is necessary for the authorized representative of the patient in order to form an informed decision of continuing or withholding the treatment. Such informed decision would be based on the professional obligation and moral responsibility of the medical doctor to provide all sufficient information, including possible alternatives necessary for evaluating a proposed medical opinion before undertaking any further action (Pozgar, 2011).
Francois de La Rochefoucauld wrote: “Hope is the last thing that dies in man; and though it is exceedingly deceitful…” (Pozgar, 2011). There are moral, human, and ethical reasons why it is always impossible and painful to decide upon the most appropriate course of action with patients in the comatose or vegetative state. In the epoch of high technologies, people have sometimes unrealistically high expectations for the medicine. Especially, it is true for people who are willing to do anything in order to see the smile on the face or hear the voice of the loved one again.
In a conflict over the patient who is not completely brain dead but in the comatose state for a long time, both sides have intelligible point; they have different motivations. Those who are in favor of continuing the medical intervention are driven by hope and faith in the medical miracle. They are convinced that with the help of technologies they have an opportunity to live until the scientists will invent a cure from their condition. Those who are in favor of withholding the intervention want to give rest to the patient. They are honoring his/her human dignity in such a way because some people prefer death over being indefinitely chained to the ventilation. Thus, while dealing with serious brain damages the clinicians are ethically obligated to explain the condition of the patient and the possible outcomes of the condition. They have to be honest and competent. They have to examine thoroughly all the pros and cons of the patient’s condition, including the case when the outcome is invariably negative and there is no hope. Regardless of the fact that physicians have to balance uprightness with the promotion of hope, it is their responsibility to tell a family that their loved one will not recover and will forever remain in the comatose state (Pozgar, 2011). In such cases, false hope is more brutal than tough truth. First of all, prolonging of the agony is never a good thing; secondly, the mechanical support of the respiratory and cardiac functions is extremely expensive. Therefore, no matter how painful and devastating it will sound for the family – the truth has to be told because the mechanical devices only provide the illusion that the person is still alive (Wijdicks, 2011).
Actions That I Would Take
My actions in such a situation will depend on the patient’s will and the letter of the law. I will not be concerned about any allegations of the patient’s relatives about mercenary ends of the next-of-kin. First of all, I will ask the attending physician to give the reasonable evaluation of the patient’s chances to recover. In case the attending physician will give the negative prognosis of recovery, such as about zero percent of statistical odds, I will ask for the existence of the advanced directives: a living will or a durable power of attorney. Both documents are legal documents that communicate the patient’s wishes concerning his/her healthcare decision-making in case of his/her incapability of making such a decision. These documents relieve the relatives from making hard decisions and prevent any arguments about his/her healthcare. In case of availability of those documents, I will involve a hospital lawyer to certify their legality. In case of absence of the advanced directives, I will ask the hospital lawyer to establish the next-of-kin according to the order of precedence in the United States.
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In our time of high technology, it is often difficult to explain the chances of a patient from the medical perspective. The progress of new technologies is prompt, and it gives some relatives hope that their loved ones will have the chance to recover in the future. Therefore, as an administrator of a hospital, I will personally see that the attending physician gave all possible information to make a decision for an authorized person. The attending medical doctor is the most competent person concerning the condition of a patient; he/she knows the extent of damage, results of all the medical tests, and statistical odds of recovery with similar brain injuries. Despite each human organism is unique, there are some commonalities and scientific laws that nobody can break. Therefore, in the end of the day, the competent and experienced attending medical doctor has a pretty good understanding of the patient’s chances. If the authorized person will need the second opinion, I will organize it. The decision of withholding or continuing the mechanical support of a human life is extremely stressing and unsatisfactory. Thus, my duty is to be sure that the authorized person obtained as much information as he/she needed to form a reasonable and informed decision.
After making sure that the letter of law is followed and the authorized person obtained all the necessary information that he/she needed, I will follow and support any decision that the authorized person made.
Resources That I Would Employ
The resources that I would involve are the medical opinion of the competent attending physician and service of a hospital lawyer. In case of necessity of second medical opinion, I will engage the services of prominent medical professionals on cognition and brain science. I will negotiate considering the ethical and moral concerns of both sides, but in decision-making, I will respect the decision of a legal representative of the patient.
- Pozgar, G. D. (2011). Legal aspects of health care administration (11th ed.). Jones & Bartlett Learning.
- Wijdicks, E. (2011). Brain death (2nd ed.). Oxford University Press.