One of my duties, beyond my direct patient responsibilities is serving as a member of the hospital ethics committee. We meet monthly to discuss cases by request of anyone involved in the care of the patient (usually the attending but not always). In almost all cases, we generally come to a near unanimous agreement, but one recently came up which left us pretty divided and I also found myself in the minority opinion. Here's your chance to be a medical ethicist. I modified the medical details of the case to protect patient confidentiality but the ethical issue is left intact.

An 80 year-old man was admitted to our ICU about a month ago with cardiac arrest and coma. A head CT scan showed diffuse swelling in the brain (often a complication of brain injury due to lack of oxygenation). Based on this information, his neurological examination and other medical complications that arose (severe pneumonia, renal failure), it was universally agreed by his physician team and consultants that his prognosis for any meaningful recovery was grim.

There were basically two options at this point. The first option is to be medically aggressive and continue to manage patient's numerous complicating medical issues but understanding that little could be done for the brain injury. In addition, he would also need a feeding tube and a tracheostomy (a more permanent type of breathing tube) both of which are fairly invasive procedures. Once his medical issues stabilized, he would then be sent out to a chronic care facility where he could conceivably remain in this state for months or even years. The second option would be to stop any proactive care (no antibiotics or nutrition, removing the breathing tube, no blood draws for labs etc.) and administering medications only to keep the patient comfortable (i.e. morphine) understanding that the patient would soon succumb to his multiple medical issues. Two very tough, agonizing decisions.

As there was no designated health care proxy or living will, the medical decisions were left to the patient's three children, two being local, but one living out of state. Further complicating the issue,the family is non-English speaking but the situation was explained in multiple meetings to all members through medical interpreters and through the English speaking grandchildren of the patient and it was felt they sufficiently understood the situation. After about a week, the patient's children opted to withdraw care, except that they did not want the breathing tube stopped as they wanted their sibling from out of state to come and see the patient before he died. The medical team agreed.

For whatever reasons, the out-of-state daughter delayed her arrival for almost a week. During this time, the patient not only survived (despite not getting any active treatment for his issues) but his neurological examination slightly improved in that he opened his eyes and demonstrated brainstem reflexes that were previously not present on his initial examination but was unresponsive otherwise (what we call "coma vigil" somewhat like a vegetative state). When she arrived, seeing that the patient looked "better" than she was told, she unilaterally reversed the family decision to withdraw care and insisted that full care be re-established including plans to put in a permanent feeding tube and tracheostomy. Privately, the other brother and sister confided to the medical team that the patient would definitely not want that but for the sake of family harmony, they wanted to defer to this sister. In addition, the sister had unrealistic expectations as her reasoning to maintain aggressive care is so that she could take the patient to China and get stem cells treatments which might "cure" him or at least wait until such treatment was widely available. At this point, the medical team refused due to the fact that such measures were futile and would put the patient through unnecessary invasive procedures which the other family members had previously expressed was not what the patient wanted. They also raised objections based on that fact that part of this decision was based on this irrational "stem cell" plan. However, the other family members acquiesced to their sister's position and insist on reinstituting full care.

A couple issues to consider as well about this:

While this remains unresolved, the patient remains parked in the ICU. At this point, the hospital is losing money on this patient (insurance will only cover hospital days consisting of active medical care). In addition, this is one less bed available to accept another patient that may require ICU level care.

Doctors do have the right (even the responsibility, some would say) to refuse medical care deemed "futile." However, for medicolegal reasons, this would usually require the hospital going to the courts which is really a messy situation that we never want to do.

As this is an active case, I'll be sure to post an update as it unfolds and my own thoughts on the situation.