Courtesy of New York Magazine | 06.08.2008

Aethics080616_2_198 mother of four children entered the hospital after suffering a massive stroke and was put on a ventilator. Doctors believed that she would not regain brain function. One of her sons got to the hospital first and told doctors that should his mother suffer heart failure or any other irreversible complication, no measures should be taken to save her life. Doctors worked under that assumption until one of the woman’s daughters arrived and claimed that her brother wasn’t interested in helping their mother. He had pushed to put their mother in a nursing home, the sister said, and added that she wanted to do everything possible to extend her mother’s life. The mother was widowed and hadn’t specified which of her children was to make decisions on her behalf. Doctors had to choose whose wishes to follow.

The Issues
Without a spouse involved, the responsibility for end- of-life decisions falls on a patient’s children, and without a designated health-care proxy in place, all the children hold equal weight. In cases like this, doctors have to focus on what the patient, not her children, would want, says Nancy Dubler of Montefiore. That means looking for examples of “substituted judgment,” or statements that the patient may have made that give clues about her wishes. If, while watching ER, say, the mother had commented that she would rather be unplugged than be kept in a vegetative state, that sentiment would hold more weight than any of her children’s opinions on the matter. “Everyone should be asked to contribute recollections about her,” says Dubler. “What was her relationship to medical care? Did she express wishes about what she would want in this sort of circumstance?” If no good evidence emerges as to the patient’s wishes, the hospital’s dispute-mediation team has to step in.

The Outcome
Until the legal and ethical issues could be resolved, the ethics team told the children that a Do Not Resuscitate order would not be put in place. They also told the children that there was nothing more that could be done for the mother to reverse her condition. In the course of the consultation, the siblings discussed how their mother responded to the Terri Schiavo case. They remembered their mother saying she thought it was terrible. “They should let that girl die in peace,” they recalled her saying. Everyone, including the sister who had initially rejected the idea, agreed that the mother should not be resuscitated in the case that her heart failed. She died shortly thereafter.