When surrogates override wishes

Alex Smith points out a fascinating paper and teaching video that recounts the story of two daughters who override the wishes of their 83 year old mother regarding life sustaining treatment. Alex summarizes the story this way:

  • An 83 year old woman with complex medical conditions becomes septic and is seen in the emergency department.
  • She has an advance directive that clearly states “Do Not Resuscitate, Do Not Intubate,” designating her oldest daughter as her surrogate decision maker.  She talked with both daughters about her wishes.
  • The doctors ask her daughters for permission to place her on a ventilator
  • The patient, very ill and turning grey, says “no-no-no” and wags her finger
  • The patient becomes unresponsive, and the daughters grant permission to intubate her and transfer her to the ICU

Even more interesting than the paper, the daughters agreed to be videotaped discussing this case (“Twenty-two days and two blinks of an eye”), which eventually ended when they decided to have their mother de-intubated and she died. As both the paper and video show, this is a far more nuanced story than someone simply not following the wishes of another person at the end of life. Instead, it touches on many issues: communication, consent, leeway, who preferences/needs should be included in end of life decisions, and how to deal with differences within families on these very difficult choices. Further, your mother only dies once, so it is the health care system that needs to work on learning from difficult experiences and trying to make it more likely that bad ones are not repeated.

I have shown the video to several people who had very divergent feelings after viewing it, so I pass it along without any more comment, except to say that these two daughters are very brave for allowing this story to be shared so publicly.

DT

Peter M. Abadir, Thomas E. Finucane, Matthew K. McNabney. When Doctors and Daughters Disagree: Twenty-two Days and Two Blinks of an Eye. J Am Geriatrics Society 2011;59(12):2337-30.

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