Often a patient-advocate has to transcend artificial boundaries to counsel her clients in an objective, value-free manner
Because a doctor-patient relationship is so personal, intimate and special, it often raises a number of ethical dilemmas. One major controversial issue, a discussion of which often raises more heat than light is: how do we define death?
A competent, adult patient may, in advance, formulate and provide valid consent to withholding or gradually withdrawing life-support systems, but if these advance directives are not available, then a patient advocate should be able to counsel the patient’s family in reaching the right decision that serves the best interests of the patient. Patients should also be able to appoint surrogate decision-makers who can make decisions on their behalf, in case they are not able to, in accordance with the prevailing law.
This kind of a decision-making is often vested in:
- The patient’s legal guardian
- The patient’s spouse
- An adult son or daughter
- Either parent
- An adult brother or sister
- An adult grandchild
- A close friend
- The guardian appointed by the estate
Physicians Please Note
In recognising the legitimate role of advocates, physicians should be prepared to fully discuss:
- Limitations imposed on their participation by privacy laws and other statutory and regulatory requirements and
- How other legal instruments, such as power of attorney, living wills and advance directives may affect their roles.
If there are multiple surrogate decision-makers present, they may be asked to reach a consensus on behalf of the patient. If there is conflict among them, this will need to be resolved. Though the surrogate’s decision for the incompetent patient should almost always be honoured by the doctor, there can be four exceptions to this rule:
- There is no available family member willing to be the patient’s surrogate decision-maker;
- There is a dispute among family members on what decision to take
- There is sufficient reason for the doctor to suspect that the family’s decision is clearly not what the patient would have decided if she were competent; and
- If the doctor suspects that the decision is not in the patient’s best interests
Let’s take the following illustrative case:
Kartar Singh (82) is the patriarch of a large Sikh family. He suffered haemorrhagic stroke two months ago that left him paralysed and in a partially vegetative state, unable to communicate in any meaningful way. His families’, including his daughters and granddaughters began to care for him at home and have been feeding him by mouth for the entire duration of his illness. Last week however, his condition deteriorated and he is now having difficulties swallowing.
After careful discussion of the case with the family, during which Singh’s eldest daughter acts as his primary patient-advocate, it is agreed that for the time being the patient would continue with the care delivered at home. However, just as the doctor suspected, two weeks later, Singh has to be rushed to the hospital with a chest infection caused by aspiration of food into his lungs. He is treated with IV antibiotics and a drip is inserted to provide hydration and stabalises his condition. A CT head scan also confirms progressive cerebral bleeding.
On the sixth day, Singh dies peacefully in the intensive care unit of the hospital, surrounded by his loving family members. The family feels indebted to the priest and the doctor’s team, who extended them just the kind of direction and moral support they needed in their time of need.