Chapter 11: Refusal of Treatment by Competent, Informed Patients

Introduction Competent and informed patients may refuse interventions that their physicians recommend. In some cases, physicians may hesitate to accept refusals that jeopardize the patient’s life or health. Although concern for a patient’s well-being is commendable, as discussed in Chapter 4, it is important for physicians to understand the compelling ethical and legal reasons for […]

Chapter 12: Standards for Decisions When Patients Lack Decision-Making Capacity

Introduction When patients lack decision-making capacity, physicians must address two questions: What standards should be used when patients cannot give informed consent or refusal? Who should act as surrogate? This chapter addresses the first question. Traditionally, these standards were viewed as a hierarchy: advance directives take priority over substituted judgments, which in turn supersede best […]

Chapter 13: Surrogate Decision Making

Introduction When patients lack decision-making capacity, physicians turn to surrogates to make decisions on their behalf. Traditionally, family members serve as surrogate decision makers for such patients. This book uses the term surrogate for anyone who makes decisions for a patient who lacks decision-making capacity and reserves the term proxy for a surrogate appointed by […]

Chapter 14: Persistent Disagreements Over Care

Introduction Disagreements over life-sustaining interventions are common, occurring in as many as one-half of ICU cases [1]. Although disagreements are resolved in almost all cases [2], [3], in a few cases sharp disagreements persist. This chapter discusses cases in which either physicians or patients or their surrogates insist on interventions that the other party considers […]

Chapter 15: Confusing Ethical Distinctions

Introduction In discussions about life-sustaining interventions, physicians often draw distinctions that seem intuitively plausible, but prove problematic on closer analysis. Examples are distinctions between withdrawing and withholding interventions and between extraordinary (or heroic) and ordinary care. However, some distinctions, although less intuitive, are nonetheless ethically valid. For instance, there is an important distinction between providing […]

Chapter 16: Ethics Consultations and Ethics Committees

Introduction Ethical dilemmas in clinical practice can lead to deep disagreements and strong emotions. The Joint Commission requires health care institutions to have a mechanism to address ethical issues in patient care, such as an ethics committee or an ethics consultation service. Ethics case consultations might be carried out by the full ethics committee, by […]

Chapter 17: Do Not Attempt Resuscitation Orders

Introduction Everyone who dies suffers a cardiopulmonary arrest. Although cardiopulmonary resuscitation (CPR) might revive some patients after unexpected cardiopulmonary arrests, in severe illness CPR is much more likely to prolong dying than to reverse death. This chapter discusses the effectiveness of CPR, appropriate reasons for Do Not Attempt Resuscitation (DNAR) orders, the interpretation of such […]

Chapter 18: Tube Feedings

Introduction Tube and intravenous feedings can prolong life in patients who cannot take adequate nutrition by mouth. In conditions such as short bowel syndrome, parenteral hyperalimentation can allow patients to lead active lives for many years. However, in a severe, progressive illness such as advanced dementia or metastatic cancer, tube feedings might merely prolong death […]

Chapter 19: Physician-Assisted Suicide and Active Euthanasia

Introduction Although traditional medical ethics prohibit assisted suicide and active euthanasia, public opinion and policies in the United States are divided. Active euthanasia is illegal throughout the United States, and most states prohibit physician-assisted suicide. The Supreme Court ruled that there is no constitutional right to physician-assisted suicide and that states may prohibit it [1]. […]

Chapter 20: The Persistent Vegetative State

Introduction Patients in a vegetative state have no cortical function, but have preserved brainstem function [1], [2]. Thus, they have spontaneous breathing and pulse, as well as wakefulness; however, they are not aware of their environment and cannot respond to other people or communicate with them. Although persistent vegetative state (PVS) is uncommon, the cases […]