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Can I Say “No” If a Family Wants to Support a Vegetative Patient Indefinitely?
BRIEF ANSWER
Most American courts allow surrogate decision makers to withdraw or withhold treatment for certain incompetent patients. However, the exact circumstances under which such actions are permitted may vary in different courts. When surrogate decision makers and physicians disagree about continuing therapy in apparently futile cases, courts have almost always ordered continuation of treatment. At the same time, however, courts have been reluctant to punish physicians who refused treatment when the decision seemed reasonable. Despite such cases, unilateral action by physicians is discouraged for at least two reasons. First, there exists the potential for legal action (which is burdensome even if successfully defended). Second, and more important, such actions conflict with the basic ethical principle of autonomy, even if incompetent patients must exercise that principle through surrogates. Fortunately, almost all disputes can be resolved through negotiation.
Because no clinical trials are possible in this area, designations of levels of evidence and strengths of recommendations are not used in this chapter.
Background
Patients with head injury may become severely disabled, vegetative, or brain dead. Because considerable data are available about the outcomes of such patients, neurosurgeons and other physicians who care for them are in an excellent position to provide prognostic information to family members and other surrogates who may have to make medical decisions for patients when they are incompetent; that is, unable to make decisions for themselves.1 In the case of patients who are severely disabled, vegetative, or brain dead, physicians may accompany the prognostic information they provide with recommendations to withhold or withdraw life-sustaining therapy. Alternatively, families may request from physicians that life support be withdrawn before recommendations are made.
A study we conducted in the medical-surgical intensive care unit (ICU) at San Francisco General Hospital demonstrated that the families of 22 out of 24 patients who were severely disabled, vegetative, or brain dead concurred with the prognoses of neurosurgeons and agreed with their recommendations to withhold or withdraw treatment.2 In some cases, the patients were dependent on mechanical ventilation and died shortly after their ventilators were removed either in the ICU or in the operating room (the latter involved brain dead patients who were organ donors). In other cases, the patients were not ventilator-dependent and died after transfer from the ICU to the neurosurgery ward nearby, where they were not given antibiotics or other medications.
Although the majority of patients with poor prognoses had life support withheld or withdrawn in this study, the families of two patients, both of whom were vegetative, insisted that treatment be continued in the ICU, on the ward, and in chronic care facilities. Both families disagreed with the neurosurgeons’ opinions that the patients would not regain cortical function. They expressed a belief in miracles and stated that the patients would have asked for continued support if they were able to do so. At the same time, the physicians felt that further treatment could not restore the patients to a sentient existence and was wasteful of health care resources. They were tempted to refuse further treatment on the grounds of medical futility.
The infrequent physician—family conflicts documented in this study from San Francisco General Hospital occur from time to time in other hospitals in the United States, although they have not been formally described. They raise an important question: Can neurosurgeons and other physicians say “no” to families that want to support vegetative patients indefinitely? This chapter addresses this question while reviewing American biomedical ethics and law.
Ethical and Legal Considerations
In the United States, the primary legal justification for withholding and withdrawal of life support is found in the principles of informed consent and informed refusal. Both principles have strong roots in the common law, which reflects the American regard for self-determination as expressed in the ethical concept of autonomy. These principles hold that treatment may not be initiated without the approval of patients or their surrogates except in emergency situations and also that patients or surrogates may refuse any or all therapies. Currently, all American courts recognize a competent adult’s right to refuse life-sustaining treatment, although the constitutional, statutory, and common-law bases of the right may vary from jurisdiction to jurisdiction. Most of the cases concerning that right have arisen, however, from situations involving incompetent patients.3
Pearl
All American courts recognize a competent adult’s right to refuse life-sustaining treatment. Application of this principle to incompetent criticallyill patients began in the Quinlan case.
Related posts:
Should I Monitor Jugular Venous Oxygen Saturation?
Are Steroids Indicated in the Treatment of Head Injury?
Do I Need to Decompress Patients with Spinal Cord Injury Right Away?
Does Barbiturate Coma Help to Improve Outcome from Head Injury?
What Is the Outcome of Patients with Mild, Moderate, or Severe Traumatic Brain Injury?
Should Head-Injured Patients Be Taken to the Nearest Hospital or to a Hospital with Neurosurgical Capability That Is Farther Away?
