What are your feelings and concerns about caring for a patient for whom withdrawal of treatment will result in death?

Competence

Situation

M.T., a 60-yr-old man, has been awaiting heart transplantation for 6

months. He has been in the ICU for 1 month since he needed a VAD

for his failing heart. He recently had a stroke, which is a complication

of the device. It left him paralyzed on his right side. He is only able to

answer yes/no questions by shaking his head. He has needed

mechanical ventilation since his stroke. For the past 2 weeks, he has

needed hemodialysis because of renal failure. Recently, when you

suction him, he turns his head away from you and bites down on the

endotracheal tube. Although he does not have an advance directive,

his wife and daughter tell you that, on many occasions before these

events, he expressed that he would not want to live if he lost his

independence. His wife and daughter request to have the mechanical

ventilator withdrawn.

Ethical/Legal Points for Consideration

• Decisional capacity for informed consent related to treatment

decisions involves 4 elements: (1) information provided about

possible treatment options must be understood by patients, (2)

patients must have the capacity to deliberate about the treatment

choices and their consequences, (3) patients’ treatment decisions

must be freely chosen and made without coercion, and (4)

patients must be able to communicate their decisions.

• Legal competence, as determined by the courts, has a low

threshold. The ability to respond to questions by signaling a yes

or no may be enough to prove understanding of the questions,

ability to discriminate between choices, and ability to

communicate choices, providing that the answers make sense

and are appropriate. Review how your state defines legal

competence.

• Next of kin are the legal decision makers in the absence of

advance directives if the patient is unable to make decisions for

himself. Decisional capacity should be tested without assuming it

is absent.

• Some courts have accepted past assertions of preferences, past

behavior, and assertions of their parties as evidence to support

end-of-life preferences in the absence of advance directives.

• Know your agency’s policies and the local jurisdiction’s laws and

regulations about informed consent and end-of-life decision

making.

Discussion Questions

1. What would you do next given M.T.’s behavior and the

information you obtained from his wife?

2. What are your feelings and concerns about caring for a patient

for whom withdrawal of treatment will result in death?