February 04, 2009

Dilemma: Care of an Unresponsive Patient with a Poor Prognosis

NEJM Clinical Decisions Case:
Care of an Unresponsive Patient with a Poor Prognosis
Arthur S. Slutsky, M.D., and Leonard D. Hudson, M.D.
A 56-year-old homeless man was found having a seizure and was transported to the hospital. He was found to have a subarachnoid hemorrhage and acute hydrocephalus. He underwent intubation, and mechanical ventilation was started. ... The patient's condition did not improve over the next 3 days, and both the neurologist and the neurosurgeon opined that he had a chance of approximately 80 to 90% of being in a long-term persistent vegetative state and a chance of 5 to 10% of any recovery. His prognosis, at best, was to have a severe disability that would leave him dependent on care by others.
In this picture:

* A son who, under the law of the state, was the legal next of kin for making medical decisions if the patient was unable to do so himself. The son described the patient as "a fighter" who would want aggressive care until the prognosis was much more certain.
* A brother and a mother. They were all in agreement that the patient would not want to live in a state in which he would be largely dependent on others for daily care and would have severely impaired cognition.
* A counselor at a homeless shelter with whom he had talked at least every couple of weeks. The counselor came to see the patient and related that the patient had told him that he wished to avoid hospitals and that "when his time came" he wanted no aggressive medical care.
Given the lack of improvement in the patient's neurologic state, the extremely poor prognosis for any meaningful recovery of cognitive function, and the high probability of cancer, the care team strongly believed that all aggressive and supportive measures should be discontinued and the goals of care changed to those of providing comfort. The brother and mother, who had been quick to respond to queries from the beginning, agreed with the shift to comfort care. However, the son, who had become increasingly difficult to contact and rarely returned telephone calls from the caregivers, disagreed. He had hardened his position, wanting full aggressive-care measures to be taken, including clipping of the aneurysm.

What would you do?
1) Continue Aggressive Care and Pursue an Ethics Consultation with the Patient's Surrogate
2) Write a Do-Not-Resuscitate Order and Transfer the Patient to a Skilled Nursing Facility
3) Withdraw Life Support on the Basis of Substituted Judgment

Cast your vote!

My response:

I chose three online. To demonstrate my convictions, I've provided my extended comments below.
This case shows that decisions cannot be made with broad brush-strokes (all decision making must be handled exclusively by legal next of kin). Rather, it must be understood in the context of the case. The son with durable power of attorney (DPOA) is "holding the line" so to speak, on the basis that his father is "a fighter" who would desire aggressive care until a prognosis was much more certain.

Surely, this is a sentiment we can all agree with -- fighting for someone we love. However, the clarity of the prognosis and possibility for recovery is understood by all (but him) to be minimal at best. The prognosis was declared by a neurologist and neurosurgeon to be ~80-90% of being in a long-term persistent vegetative state and a chance of only 5-10% for any recovery! Even if he did recover, he would no longer be independent, something inconsistent with his values.

The father has not formally declared any DPOA, but it becomes apparent that the son is estranged and the counselor from the shelter is more familiar with the patient's desires. The son is exhibiting a common grief reaction of denial, withdrawing himself from the situation while simulataneously insisting that everything be done. Given the family support from the mother and brother and the coinciding words by the counselor, I would elect to place the decision-making in their hands and withdraw life support and provide hospice for the patient and family counseling. A full discussion of the SAH and subsequent coma should be initiated with the family with maximal encouragement to have the son attend!


  1. I recently saw a case where a daughter was extremely difficult and demanded aggressive care. She threatened to sue several times, and prevented the team from doing many interventions that she considered harmful to him.

    It was eventually discovered that she had ulterior motives: her father's will allowed her to stay in his house only while he was alive.

    I'm not saying that all difficult family members have selfish motives, but in this case, it's something to consider, especially with a son who appears eager for aggressive intervention, yet seems to avoid his family and the treatment team.