An 84-year-old woman with severe Arzheimer’s disease is admitted to your skiled
nursing facility. She has lost the ability to conrmLrnicatc, is becl_bound, ar.rd unable to
cat. she did not appoint a prorr and tbere is no rvritten or clear vcrbal advance direc
tive of ,vhat shc uanted for hersell Multiple family members routinely visit her and
1’ou are unable to achieve a clear consensus amongst the famil). of what the patieDt,s
rvishes rvere.
What should you do in terms of her care?
a. Follow the wishes of the eldest child.
b. Follow what you think is best.
Ask another attending physician’s opinion.
AsJ< the hospital administrator for consenr.
Pur.rrc an clhic: eornnrittec (\ Jludtio
(e) Pursue an ethics committee evaluation.
When there is no clear evidence of the patient’s wishes, then you must seek the best “substituted judgment.” The physician mLrst seek out what the patient would hare
wished for herself and you “substitute” the judgment of the caregivers or family for
what the patient would have wanted for herself had she been awake. When a reachable consensus by discussion is not possible then an evaluation by the ethics com
mittee is appropriate to seek consensus. This is the weakest form of decision making
because it carries the least precision. If a clear agreement still is unreachable then
referral to the courts nay be necessary to achieve clarity and objectively weight the
evidence that the different family members bring forth. This is what happened in the
Terry Schiavo case in which the patient’s husband was judged by the courts as brining
the best evidence that he and others had the most accurate knowledee of what the
patient wanted for herself.
If there is no family available then the ethics committee and physicians would
make decisions based on the judgment of what would be in the best interests of the
Parrent