Friday, February 6, 2009

Conflicts over life-prolonging care in NEJM

Last week's NEJM has an all-too familiar case discussion about a protracted conflict regarding life-prolonging treatment in a vulnerable, brain-injured man with a dismal prognosis. A case is presented, followed by 3 different discussants all proposing different 'next steps' (essentially more talk, continue life-prolonging care, or discontinue life-prolonging care). Readers can then vote as to which next step they most support, and add comments. Hundreds have done so, with a lot of interesting, and very wise (mostly) comments.

My own comment (which is now deeply buried) discusses the fact that this occured in a state in which the legal next of kin defaults as the legal decision maker and much of the conflict revolves around this NOK who was legally empowered to be a decision maker for a patient without any evidence that he 1) wanted to be; 2) the patient wanted him to be; or 3) that he was even willing to abide by the most basic of supposedly-valid proxy decision-making principles such as substituted judgment or 'best-interest.' While not having a law or court ruling which delinates who is a decision-maker creates its own set of problems, it seems particularly crazy to me to have laws/court rulings which mandate someone as a decision-maker based on some version of closeness-of-relation, especially given that a substantial minority of patients when they actually designate a health care power of attorney don't even name their spouse! Most do, of course, but some, presumably for very good reasons, would rather have their sister or daughter make those decisions for instance....

Anyway - it's great to see such a case given such prominence in the NEJM - and you can still 'vote' until February 11.

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