Ethics Roundtable: Interpreting a Living Will after Stroke
Response by David Liao, M.D.
David Liao, M.D.
Clincical Instructor of Medicine
Harvard Medical School
Spaulding Rehabilitation Hospital
Mr. Duffy' s request, "I'll go for the works" contradicts the family' s statements about his previous wishes. When critical choices are made by proxy decision-makers, health care professionals must determine as clearly as possible what the patient' s original wishes are in both this specific circumstance and overall intent. This might involve detailed discussions with family, primary physicians, friends, and/or clergy.
I assume Mr. Duffy believes that "heroic" or life sustaining treatment should be instituted if the goal is the return of some or all function or quality of life. However, in a situation that is hopeless or affords no quality of life he would not want any interventions that merely prolong his physiologic life.
In my experience, most patients agree in principle with these objectives. However, health care providers are still faced with the burdens of uncertainty about prognosis and identifying all the subjective components of this philosophy: i.e. "quality of life" or "hopeless." Immediately following a stroke no one can predict prognosis or the timetable for return of function. Despite clinical instinct or experience, the answer to "is the condition hopeless?" or "will it afford no quality of life?" is "We don' t know right now."
A time-limited trial of tube feeding could afford Mr. Duffy the opportunity to recover and possibly participate in his own healthcare decisions, recover in order to eat without risk, or both. If at the end of the trial, the situation appears hopeless or affords no quality of life tube feedings should be discontinued, based on the patient' s right to self-determination.
Hare, J., Pratt, C., & Nelson, C. (1992). Agreement between patients and their self-selected surrogates on difficult medical decisions. Archives Internal Medicine . 152(5): 1049-1054.
Tippett, DC & Sugarman, J. (1996). Discussing advance directives under the patient self-determination act: A unique opportunity for speech-language pathologists to help persons with aphasia. Am. J. SLP . 5(2): 31-34.
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