Events

NOTE: This month’s Ethics For Lunch will be held virtually.

Click here for CME Information associated with this event.

Case
Mr. Thomas, is a 45-year-old male, admitted to the hospital after collapsing at home.
After being stabilized and examined the care team identified a previously undiagnosed and aggressive form of brain cancer (glioblastoma). He is currently unresponsive, and the medical team believes his prognosis is poor. He lacks decisional capacity.

Currently, there are longer-term decisions to be made, such as whether to proceed with a risky surgery that offers a small chance of extending his life, or to focus on palliative care. Short-term decisions also need to be made. Since he is intubated and being fed through a nasogastric tube, the team is worried that if left in his current state his condition could quickly, and unnecessarily, deteriorate. Their suggestion is that he undergo a surgical procedure to receive a tracheostomy and gastrostomy feeding tube. This will require someone to give consent for the procedures.

Mr. Thomas’s only known family member is a niece who he has been living with.  In the first days of hospitalization, she was in contact with the unit case manager. After understanding the seriousness of his condition, she said she could not care for him any longer and he would not be able to return to her home. Since then, the team cannot contact her. Mr. Thomas has no other known family members or close friends who can provide insight into his wishes. He is not married and has no children. He does not have an advance directive or a designated healthcare agent. He has no known history of mental illness or cognitive impairment prior to this sudden illness.

Because Mr. Thomas did not execute an advance directive or appoint a healthcare agent, and has no readily identifiable family, the hospital must navigate the process of identifying a legal/ethical surrogate. Given the complexity and urgency of Mr. Thomas’s medical situation, and the lack of a readily available surrogate, the hospital legal counsel, in collaboration with ethics committee, determines that seeking guardianship is the most appropriate course of action.

The need for immediate medical decisions complicates the guardianship process. The hospital must balance the need to act quickly to provide appropriate care with the need to ensure that Mr. Thomas’s rights are protected and that decisions are made in his best interests.

Objectives

1. Distinguish among surrogate, healthcare agent and guardian for persons who lack decisional capacity.
2. Discuss the ethical frameworks for decision making for persons who lack capacity.
3. Identify the legal process for guardianship within Maryland.
4. Explore steps that the clinical team and hospital can take to assure that the patient’s best interests are respected.

Questions

• When a person lacks decisional capacity, what are the differences between a surrogate decision maker, a health care agent, and a guardian?
• Why / how is ensuring the appropriate decision maker is in place an ETHICAL issue? Why / how is it a LEGAL issue?
• What is the legal process in this jurisdiction (Maryland) for petitioning for guardianship in an urgent medical situation?
• How can the medical team and the hospital ensure that the appointed guardian is adequately informed about Mr. Thomas’s medical condition and prognosis and is acting in his best interest?