Ethics Roundtable: Interpreting a Living Will after Stroke
Response by Mary Spremulli
Charlotte Regional Medical Center
Punta Gorda, Florida
The ethical question appears to relate to an interpretation of patient preferences.
Acceptance or refusal of medical treatment is the legal right of a competent adult. Unlike competency, a legal term, decisional capacity may be variable, and influenced by the medical pathology itself, medications, or other reasons for fluctuating states of consciousness. When a patient's decisional capacity is waxing and waning, as appears to be the case with Mr. Duffy, one must look for consistency in the expressed preference during periods of clarity. When the patient's ability to comprehend and manipulate information is clearly compromised, and there is sufficient clinical evidence that a patient lacks decisional capacity, than a surrogate decison maker should be appointed.
If the patient's preferences are unclear or unknown, the proxy must consider the "best interest" of the patient. That is, make choices that relieve suffering, preserve or restore functioning, and impact the quality of life in a way that a reasonable person would choose. Although Advance Directives, including the Living Will, are an important tool for the expression of patient preferences, should the individual become incapacitated, they are laden with some inherent problems, as this case illustrates. Most living wills employ terms that are somewhat vague, such as: "if there is no reasonable expectancy of recovery," "have a terminal condition." One can see how the language of the living will would have to be interpreted relative to the context of this case.
When goals of intervention are unclear, the team might ask: Are the medical indications for the proposed treatment clear? What are the probable outcomes of the proposed treatment? Do the benefits justify any treatment risks?
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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