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Vol. LIX, No. 3
February9, 2007

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First, Do No Harm
Cassem Charts Ethical Answers To ‘Inappropriate Surrogates’

On the front page...

Can clinicians contravene a patient’s end-of-life choices and yet stay within ethical bounds? If the patient’s surrogate defies an advance directive, how should staff respond? An Ethics Grand Rounds discussion, “Inappropriate Surrogates: What Should Clinicians Do?” tackled the issue recently in Lipsett Amphitheater.

At age 54, a patient called EB had struggled with congenital heart disease her whole life. Now severely ill with congestive failure, renal shutdown and septic shock, she dictated her advance medical directive to her caregivers: “I want all effective treatments for keeping me alive, no matter what my condition.”


  Dr. Ned Cassem of Harvard  
  Dr. Ned Cassem of Harvard  

Clear enough. But then EB told staff to add these lines: “The impact on my quality of life is the most important consideration in making medical decisions. For me, quality of life means being be at home and independent.” She did not want to be on a ventilator; about that she was adamant. As her condition worsened, she signed a “Do Not Resuscitate (DNR)” order. No intubation, yet she did want meds administered.

“She left...a confusing advance directive,” said Joanne Pomponio, a clinical social worker who presented the case. “In her own mind, it was clear, but...”

The confusion didn’t end there. EB had appointed her aunt as durable power of attorney (DPA) and they were very close. Now the aunt was refusing to let go of her beloved niece.

“[The DNR] doesn’t matter,” the aunt insisted. “You’re going to keep treating her.” She was hoping for a miracle, she said.

EB’s relatively easy-going husband was her alternate DPA, but no match for the aunt who criticized the care, verbally blasted the staff and threatened to sue the hospital for negligence. She interfered so forcefully that she was banned from the patient’s room during procedures.

Clinical social worker Joanne Pomponio presents a difficult case at ethics rounds.
Clinical social worker Joanne Pomponio presents a difficult case at ethics rounds.
Some Terminology When Things Look Terminal
Advance directives are legal documents such as a living will that convey decisions about end-of-life care. Advance directives let patients communicate their wishes to family, friends and health care professionals and so avoid confusion later on. Even after advance directives have been signed, patients can change their minds and revise them at any time.

A health care surrogate is someone appointed to make a patient’s medical decisions if the patient is unable to do so. The durable power of attorney for health care is the legal document that names a patient’s health care surrogate and is incorporated into the medical record.

Here was an extremely ill patient who had signed a DNR, which the staff was obliged to respect. As she worsened and became unresponsive her “inappropriate surrogate” said that if staff did not resuscitate, she would sue them and the hospital too. The staff was whipsawed with conflicting demands: Doctor, let me go gently vs. If you let her go, I’ll see you in court. They were walking a very fine line and the resulting wrangle would leave questions for bioethics consultants.

End-of-life care is the specialty of Dr. Ned Cassem, Jesuit priest, consultation psychiatrist at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School. He offered these answers to a full house:

  • Could the staff advise the patient that her choice for DPA may not be appropriate and encourage her to appoint someone else? Even though she may be “the aunt from hell,” Cassem said, staff should not interfere with the patient’s choice. EB had a very close relationship with her aunt, who had no children of her own. “You might as well face it,” he said. “Never expect a mother to give up easily on a child”—the corollary being, don’t expect the aunt to give up easily on her niece, who in her heart is the child God gave her to protect.
  • Are there circumstances that would permit removal of a DPA? Yes, as when the aunt was banned from the room during procedures. Cassem recounted another case in which a family member “threatened to kill the doctor and the nurse. This lady sued me before she even met me and, due to her streams of loud obscenities in the critical care unit, we had to get security to remove her multiple times.”
  • Could staff remove EB from the ventilator based on her written instructions even if the DPA refused? Could a DNR order be put into place without the DPA’s agreement? Yes to both. “The first law of ethics,” said Cassem, “is do no harm. All doctors and nurses are bound to this first law by their oath.” EB wanted treatments that would work toward getting her home. “You just have to ask, Will [a ventilator] help her get home? No, and nothing else will,” said Cassem. “We must never use harmful treatments.”
  • How should staff handle patient/family decisions and choices that appear to be inconsistent? To help patients and families accept the impending death, Cassem suggested using some key phrases: “Your mother is a great person. At this time we want to celebrate her life, to thank her for all she’s done and to make sure her dignity is protected.” He reminded staff that resuscitation can be not only futile, but also harmful, and recalled a patient with breast cancer metastasized to the bones. “CPR would have broken her ribs. It would have been murder,” he said. “Death is as sacred as birth. We owe it to all we serve to make sure that this sacred life does not end with an act of senseless brutality.

“Even though patient and family may not practice organized religion, spirituality itself is close to universal,” Cassem explained. He stressed the appropriateness of some sort of ritual to include all family members together with the patient in the final hours to support and hold him or her and thus provide “a safe passage.”NIH Record Icon

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