Surrogate Decision Making and Truth Telling in a Rehabilitation Case.

Feature Editor IntroductionSurrogate decision making is a critical bioethical issuethat has been addressed by courts, policies, and medi-cal practices. Most states have laws that dictate towhom clinicians should go if a patient lacks the capacityto make decisions; in Illinois, for example, a hierarchi-cal list of surrogates guides clinicians in the absence of adurable power of attorney for health care. However, thecontext and complexities of family and surrogate re-lationships can make the process of surrogate decisionmaking very complicated. In fact, navigating psycho-logically and socially complex relationships that areunder stress as a result of a traumatic injury can lead toa host of ethical, moral, and sometimes legal issues forclinicians. The importance of this situation cannot beoverstated in the rehabilitation setting, which includesmany patients who do not have the capacity for complexdecision making.Over the years I have seen cases in which I doubtedthe surrogate’s capacity, as well as whether the surro-gate was acting on the patient’s beliefs or wishes or inthe patient’s best interest. However, the case framed inthis article brings up issues of complicated relation-ships, emotional reactions, feelings of split loyalties,and truth telling. Who deﬁnes or decides what is rightand wrong? What obligations do the treating team haveto different parties?In bioethics, truth telling is typically framed as anissue regarding clinicians’ sharing medical informationdfor example, HIV status or prognosis. In the followingscenario, which is an amalgamation of several cases, thetruth involves personal information that the patient hasnot told his family. It raises issues that highlight thecomplexities of working on a rehabilitation team, surro-gate decision making, and managing information.I have asked 5 respondents to comment on this case.Carol Levine, who directs the Families and Health CareProjectattheUnitedHospitalFundandisaFellowoftheHastings Center, discusses professional ethics and familydynamics.JeanneHoffman,arehabilitationpsychologistat the University of Washington and an expert in spinalcord injury rehabilitation, discusses the difference be-tween medical and personal information and the chang-ingrolesandbestinterestofthepatient.JasonByronandRobert Arnold, medical ethicists from the University ofPittsburgh,focusonthecoreethicalissues,tacklingthemfrom the perspectives of the patient, family, and careteam.Finally,AndyKondrat,abioethicist(andcolleague)attheRehabilitationInstituteofChicago,discussesmoraldistress in the context of team dynamics.If you have cases or topics you would like to proposefor future Ethical/Legal columns, please contact me atdmukherjee@ric.org. I welcome your feedback andcomments as well.Case ScenarioMr Jones, a 54-year-old man, was involved in a motorvehicle crash approximately 2 weeks ago and sustaineda spinal cord injury (SCI) and mild traumatic brain injury(TBI). He is currently an inpatient on the rehabilitationservice and has waxing and waning decisional capacityas a result of mild cognitive impairments. His wife of 23years is his surrogate decision maker for complex med-ical decisions. Mrs Jones has been at his bedside crying,and Mr Jones has told staff members that he feels guilty.During the course of treatment, it was revealed thatMr Jones was having an affair and was involved in theaccident when he was with his lover, Ann, who sustainedminimal injuries and was discharged from acute care.His wife believed he was out of town and was stunned toget a call from the hospital about the accident. WhileMr Jones was in a confused state, he called out for Ann,and his wife has become suspicious. Mrs Jones has beencoming in regularly to visit Mr Jones and has now beenasking the staff about what happened and who he waswith when he had the accident. She has restricted his