A Case of Clinical Ethics Consultation:
Helping the Care Team Help Patient Patti
A page to the Ethics on-call consultant came at 4 PM on a Monday afternoon. The consult order had been placed by the new attending during the third week of hospitalization for an incapacitated and unresponsive patient in the medical ICU. The requestor’s reason for consulting ethics: “Assistance requested in complex case of anoxic brain injury patient with unreliable DPOA and potential conflict regarding goals of care.”
“Patti” was a 52-year old woman with history of asthma, chronic pulmonary obstructive disease (COPD), Hepatitis C, and polysubstance abuse. She presented to the emergency department after cardiac arrest at home with subsequent return of spontaneous respiration (ROSC). Upon examination and MRI, findings were consistent with diffuse anoxic brain injury. Neurology was consulted and confirmed both the diagnosis and prognosis of “little, if any, chance for meaningful recovery.”
The medical team met with Patti’s husband at bedside. After extended discussion, he expressed understanding of the gravity of his wife's situation, but remained hopeful that "maybe a miracle could happen." He wanted to give his wife "a little more time" while he discussed the care plan with family members. Patti had left no written advance directive, so treatment decisions were by means of substituted judgment. Of later significance was an early conversation shortly after admission. When asked by the attending physician what Patti would want, her husband said, “Well, she wouldn’t want to be a vegetable.”
After a week in the hospital, the medical team began daily attempts to engage the husband in conversations around the patient’s prognosis and her goals of care. He reportedly would no longer participate in conversations and stopped coming to the hospital. The spousal surrogate rarely would answer his phone or respond to voice messages. When contacted, he might agree to come for a family meeting, but then would not show up, or not at the agreed upon time. This went on for another week.
Palliative Care was consulted to assist with goals of care discussions and to support the husband during this emotionally difficult time. Ethics was similarly consulted to assist with a situation that was challenging on multiple fronts, ethical also.
In most cases, ethics consultants communicate directly with patients and/or their next of kin, in addition to the care team. In this case, there was bedside observation, but no direct contact with the patient’s family. In a situation of stymied communication process, it was deemed more helpful to support the care team in their communication efforts, and to provide ethics perspective with procedural recommendations and “what if” options.
The palliative care team ultimately was able to engage the spousal surrogate in conversations both by phone and in person. His absence seemed due to emotional avoidance, but also illness and lack of resources for transportation. Social Work subsequently provided cab vouchers to and from the hospital to assist his participation in establishing goals of care for Patti. This was an obviously difficult conversation for the husband, but socioeconomic barriers also were a significant problem to his participation, a factor unanticipated even by Ethics.
However, cab vouchers and empathy did not fully resolve the issues that had triggered an ethics consult. Even with multiple attempts by many care providers to provide family support and facilitate communication, the husband continued to be absent and avoidant of decision-making. Palliative extubation was scheduled and then canceled upon no-show of family. Another week passed. Care team discussions led to a “unilateral” decision to place a “Do Not Attempt Resuscitation” order on the chart. Ethical grounding could be found for decisions in keeping with the patient’s best interests, reasonable goals of care, and accepted standards of care. This was documented in the electronic medical record by Ethics consultants.
Ethical, compassionate, and aggressive palliative care continued while further attempts were made to collaborate with family. Despite ongoing life support, Patti’s body gave out, and she died on the vent. It was not the sort of ending envisioned by Ethics or anyone as optimal and timely. One imagined for Patti an anticipated death in which she was attended by loving family members at the bedside, having had opportunity to say goodbye.
Not everything involving humans can be orchestrated just as we wish. Multidisciplinary team collaboration nonetheless resulted in a better demise than Patti might have experienced otherwise. Doing “better than” is sometimes the ethically best we can do.
Tarris Rosell, PhD, DMin
Kristyna Tan, LMSW