Ethics for Lunch: Determining the Appropriate Authorized Decision Maker
The Johns Hopkins Hospital Ethics Committee &
The Johns Hopkins Berman Institute of Bioethics
Password: Ethics
Background:J.R. is a 72 year old male with advanced ischemic cardiomyopathy who is admitted with an exacerbation of congestive heart failure. Diuresis is complicated by worsening renal insufficiency, so he is placed on a milrinone drip IV. On hospital day 11, he develops an aspiration pneumonia and requires initiation of high-flow nasal cannula (HFNC). He continues to deteriorate despite maximal medical therapies and there is concern that he may need intubation and mechanical ventilation for worsening hypoxemia. He has delirium and is deemed to lack decision making capacity. He has three adult children; his daughter and son visit the hospital regularly. His oldest son visited once in the early part of the hospitalization but has been difficult to reach since then. When asked in his obtunded state, the patient indicates that he would like his oldest son to be involved in medical decision making. Also visiting the patient is his lady friend of 40 years; they live together. The patient is divorced from his first wife, his children’s mother. When asked about who should be the patient’s authorized decision maker, the two children who visit indicate they think his significant other should be the decision maker. When the team is able to reach his oldest son, his son says he thinks his father should make his own decisions. During a family meeting, the two children and his lady friend state that the patient has previously told them he does not want to be on a ventilator. Currently the patient is not able to say one way or another what he wants.
Questions:
- What is the process for determining an authorized decision maker?
- What is the difference between a health care agent and a surrogate decision maker?
- Are there limits to decisions that a surrogate decision maker can make?
- What counts as evidence of a patient’s prior wishes with regard to life-sustaining treatments?
Objectives:
- Describe the process for determining the legally and ethically appropriate authorized decision maker for an incapacitated patient.
- Discuss the hierarchy of surrogate decision makers in Maryland law.
- Discuss the requirements of the Health Care Decisions Act with respect to legally authorized decision makers and decisions about life sustaining treatments.