Substitute Decision Making in End-of-Life Care
Case Vignette
A Woman without an Advance Directive
Lisa Caulley, M.D., M.P.H.
Three days ago, you were called to the intensive care unit (ICU) to examine Ms. Smith, a 70-year-old woman who had presented to the emergency department earlier that day with progressive shortness of breath. Ms. Smith had reported fatigue, progressive dyspnea, and intermittent fevers over the previous several days. She had a history of uncontrolled type 2 diabetes. She was accompanied by Ms. Jones, her neighbor and close friend of 10 years. She was febrile (temperature, 39.0°C [102.2°F]) on presentation and had severe dyspnea, with a respiratory rate of 34 breaths per minute. Laboratory investigations showed leukocytosis (19,000 white cells per cubic millimeter), and a chest radiograph showed dense opacities in both lungs. The trachea was intubated immediately, and broad-spectrum antibiotic therapy was initiated. In the ICU, H1N1 influenza was diagnosed on the basis of results of a real-time reverse-transcriptase–polymerase-chain-reaction assay; blood and sputum cultures were positive for Escherichia coli. Ms. Smith’s condition deteriorated into septic shock, with signs of acute respiratory distress syndrome (ARDS) and acute renal injury.
When you check on Ms. Smith’s condition today, you find that despite intensive medical treatment, her condition has not improved. She does not meet clinical criteria for extubation and continues to require ventilatory support; in addition, the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (Pao2:Fio2) is falling. Anuria and severe renal dysfunction have developed within the previous 24 hours (estimated glomerular filtration rate, 15 ml per minute), and she has had to undergo dialysis.
Ms. Smith does not have an advance directive. There is no written indication of her wishes, and no designated surrogate decision makers are available to address her goals of care. Her brother, who is her closest family member, has not been in contact with Ms. Smith in more than 20 years. He is uncertain of her end-of-life wishes but is reluctant to consider a “do not resuscitate” (DNR) order. Ms. Jones states that she and Ms. Smith had discussed end-of-life care on several occasions. In speaking with her friend, Ms. Smith had indicated that she would not want life-sustaining measures to be instituted if she were faced with severe critical illness and had said clearly that she would not want to be resuscitated. Ms. Jones feels certain that Ms. Smith would not want resuscitation measures taken.
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