Committee consultation to override family wishes.

Ms. B, a seventy-five-year-old woman, was transferred from a nursing home to the hospital when she developed a urinary tract infection from an indwelling catheter placed to control incontinence. She was extremely weak in all four limbs due to multiple strokes that related to uncontrolled hypertension, poorly controlled diabetes, and cigarette addiction. She was unable to speak because of her brain stem infarctions and a permanent tracheostomy. Although she opened her eyes, she gave no consistent nonverbal responses to simple verbal or visual questions. A neurological consultant indicated that there was no chance that Ms. B's neurological function would improve. There had been no prior contact between Ms. B and her current caregivers, and they had no indication of her wishes concerning the use of life-sustaining treatment. The attending physician attempted to meet with her adult children, but they failed to keep several appointments. When they finally met, Ms. B's family was unable to supply information about her values and preferences concerning the use of life-sustaining treatment. Her children did consent to the insertion of a feeding gastrostomy to replace her nasogastric feeding tube, but they steadfastly refused to make their mother a "Do-Not-Resuscitate" (DNR) candidate. They stated that she was worth saving at all costs. The attending physician and the primary care nurse told Ms. B's children that the former planned to consult with the hospital ethics committee to gain its support in writing a DNR order to override their wishes. To their surprise, the family did not resist, but agreed to an ethics committee consult. Should an ethics committee have a role in this case? Would an individual clinical ethicist be better able to resolve the ethical dilemma? Should consent from Ms. B's family be required before the attending physician requests an ethics committee consult? Commentary The seemingly endless array of lifesustaining intervention available in contemporary medical practice creates a difficult dilemma for physicians in this era of cost containment. The conflict they experience between their desire to respect the wishes of an incompetent patient's family and their reluctance to commit critical care resources to those with little or no hope of meaningful recovery is well illustrated by the case of Ms. B. Many health care givers have felt forced to limit care for a patient for whom treatment seems medically futile in the face of unrealistic family requests by using such strategies as "slow" codes "show" codes or "walk slowly" codes. These practices are impossible to defend from a moral perspective, for they exclude the relevant parties from discussions concerning medical choices. However, those closely invloved in patient care, especially nurses, argue that most DNR deceisons, if considered at all by physicians or families, are made at a distance from the bedside with little attention to the patient. This is an equally deplorable moral situation. There is no obligation to provide care that has no acknowledged benefit. The dilemma is the case of Ms. B is created by lthe difficulty of determining whether there is any benefit to her from treatment and by the uncertainty about who should decide what constitutes benefit-or lack thereof. A safe ehtical assumption is that the decision regarding the trade-offs should not be left only to the physcians treating her because of current pressures on physicians emanating from hospital administrators and the managed health care sector to reduce health care expenditures. If not her physicians, who should take the first step toward a decision about Mr. B's care? …