American Speech-Language-Hearing Association

Ethics Roundtable: Interpreting a Living Will after Stroke

Response by Charles Wagner

Charles Wagner
Gastroenterologist and Chief Medical Officer
Holy Redeemer Health System
Meadowbrook, PA

Several important questions are raised by this case. Who will decide about the feeding tube and how comfortable will the patient, his family and the staff be about the decision? How does a patient express his or her intent and how does that intent get interpreted when the context of the situation has changed?

Mr. Duffy has given contradictory instructions. He has a living will which states he does not wish to have his life sustained with a feeding tube, yet when he became alert following his stroke he said "I' ll go for the works". His comment about his relative with cancer having things go on too long is not as difficult to deal with as his comment there is about the relative' s situation, not his own, and thus need not be extrapolated to different conditions.

If Mr. Duffy is competent after his stroke, not confused or disoriented and if his communication difficulties of hearing and speech are worked through, he can make his own decision. He can override his prior Living Will and there is no role for the surrogates to make a decision.

If he is unable to understand, then it is the responsibility of his daughters to make decisions about his care since his wife is not able to. It is important that his daughters have accurate information about his medical condition and prognosis as well as the alternatives available. They should be encouraged to make decisions as though they were making them for him, from his perspective, not just their deciding for him.

Mr. Duffy' s "go for the works" comment is important, as it is his last communication on the issue. It needs to be assessed though, to be sure that the situation was fully explained to him and that he was able to hear, understand and communicate his wishes accurately. Also, was his comment made in the belief that he was going to remain as alert as he was when he made it, or was there consideration of what he would want if he were to become and remain disoriented again?

Thus, there are multiple questions to be considered. His daughters now have the responsibility of coming up with an answer, but it is everyone' s responsibility to help them identify all the components to be considered.

Related Readings

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.

To submit cases or to be added to the list of respondents please contact: Helen Sharp Department of Speech Pathology and Audiology, 307 WJSHC University of Iowa, Iowa City, IA 52242. Phone: 319-335-6596, fax 319-335-8851, e-mail: helen-sharp@uiowa.edu

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