Case Study – Decisional Capacity of the Patient’s Surrogate

Case Study – Decisional Capacity of the Patient's Surrogate

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By Ryan Pferdehirt, DBe and Tarris (Terry) Rosell, PhD, DMin, HEC-C

February 2024

Bioethics case study on decisional capacity of the patient’s surrogate.




Debra is a 66-year old patient who was admitted to the hospital after suffering a stroke. She was intubated upon admission fifteen days ago and has remained nonresponsive. The medical team believes it is time to have the conversation about whether to: (a) go forward with a tracheotomy plus insertion of a PEG tube for feeding, or (b) withdraw life-sustaining treatments and focus on comfort.

Debra’s electronic medical record includes healthcare durable power of attorney documentation (DPOA) naming her spouse of 18 years, Joseph, as surrogate decision maker. However, Debra apparently had not completed a healthcare treatment directive indicating her wishes involving treatment decisions and Joseph says they never talked about things like this.

Joseph is in his late 70s and exhibits signs of mild dementia. As far as is known to Debra’s care providers, Joseph has no specific diagnosis. He just appears confused when information is provided, lacking comprehension of what is meant by a tracheotomy or PEG tube, even when explained over and over again, simply, slowly, and using pictures. He has asked his wife’s physician to repeat the information multiple times. Then Joseph just shakes his head and says, “I don’t know, Doc. I don’t get it.”

Finally, Joseph says, “Okay, just do the operations. That’s what you’re asking, right? I don’t know why you have to put a hole in her neck, but I know that my wife needs to breathe. So do it. And of course she needs food and water so she doesn’t die. She’d probably hate tubes coming out of her; but I can’t live without my wife, so do what you have to do to keep Debbie alive.” Then Joseph stops and looks perplexed again. “I’m sorry. What were we talking about?”

Debra has a 35-year old daughter named Sierra, Joseph’s stepdaughter, who is at her mother’s bedside as well. Sierra seems to have no difficulty comprehending the situation, and she has a different perspective on what should be done. Sierra says that her mother “would never have wanted to be like this,” to be kept on a breathing machine or be fed through a tube in her stomach. “If you were to ask my mom, she would definitely say NO to all of this.”

With an adult daughter saying “No” to a trach and PEG and a DPOA spouse of questionable capacity saying, “Do it,” the medical team asks for ethics consultation. What should be done for Debra?

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