nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Tuesday, July 13, 2010

Ethics And Certainty: Medical Decisions For Those Unable To Decide For Themselves

Interesting case:  Are relatives able to act as the patient would have wished about terminating life support?

From the BBC News (July 13), a case where a young man becomes a paraplegic after a motorcycle accident.  Unable to move or speak, and on artificial ventilation, the family asserts that, from their knowledge of statements he has made, he wouldn't want to live like this.

Enter the neurologist, who uses the fact that the injured man can move his eyes to ascertain that he is indeed awake and alert, understands his situation, and that it's unlikely to change...and can answer questions.

And he definitely wants to continue to live.

As the father later recounts (from the article linked above):
"It's all hypothetical and you don't know until it happens to yourself. As a family and friends, if that person can't decide for themselves, sometimes you feel that you can decide for them. Because, in theory, you think you can never live in that situation, you sometimes put that judgement onto somebody else. At the end of the day, you probably have no right to do that.  But now Richard's in the situation where that's actually happened. It's real life - it's not pretend. He is in that situation. The will to live takes over."
One lesson from this is that what people say ("if that happens to me, pull the plug"), may not be what they really think when confronted with it.

The second lesson asks a question:  how do you that what somebody said a year ago (a month ago? a day ago?) is what they still believe?  People change their minds...often.

Current law gives the individual the right to decide about extraordinary efforts to sustain life.  When they are unable, the authority passes to the closest relative (or the courts)...presuming they will act in the individual's best interest.

But do they?  How do they really know what the individual "would have" wanted?  In the case above, the father, and the family, would have made the wrong decision.

Can the responsible authority (the family member) substitute their own assessment of what the decision "should" be?

Most of us would say that it's proper to go to extremes to determine the individual's desires asking.  Absent depression, or mental competence, that should be it.   Once all efforts to extract a competent decision from the patient have been exhausted, the legal guardian (closest family member, the court) should decide.

But as the case above shows, they can be wrong...there's no guarantee.

Food for thought, if you're ever part of end-of-life decision making for a relative.

Doc D

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