Question

Scenario: You are a member of your hospital's medical ethics committee which has been presented with the following issue for consideration and recommendation. An elderly male patient with multiple co-morbidities was admitted to your hospital three days ago with an acute heart problem. Upon his arrival to the emergency room, it was determined he needed to have a pacemaker implanted to keep his heart in proper rhythm. Due to his unstable condition and other medical problems, surgery was not an option at that time. Therefore, a temporary external pacemaker was placed on the patient by the cardiologist to "buy some time" until his medical condition could be fully assessed and other decisions could be made. The patient continues to be unable to communicate at this point but has a Living Will, which states he does not wish to be kept alive by artificial means, etc. if he is terminally ill or permanently unconscious. The doctors are concerned at this point because the longest a temporary pacemaker is supposed to stay in place is 3-4 days due to other complications it can cause and needs to be replaced with a permanent pacemaker as soon as possible. However, the prognosis is not good, and the doctors don't think he will even survive the surgery—they believe that the criteria required by the Living Will have been met.

Notwithstanding the Living Will, the patient's wife and family maintain "he is a fighter" and if the patient could speak for himself, he would want to take a chance with the surgery. Accordingly, the wife and family are insisting the cardiologist accept their consent on behalf of the patient for the procedure. It is noted there is a possibility the patient might be competent enough to communicate if they take him off of his strong pain medications long enough to get a response from him. However, by doing so, the patient will then be in a great deal of pain.

What are some of the legal and ethical issues the committee has to consider? Should the hospital just invoke the Living Will and remove the temporary pacemaker?

Are there any problems in removing the pain medications (the patient's comfort care)—if so, what are they?

Should the wife have the ability to overrule the Living Will? Does she have that ability?

What recommendation should the committee ultimately make to the physician and/or the family?

Answer 1

In enforcing a living will, the hospital has to take larger concern about the legal and ethical issue concerning the matter. In USA living will is legal in all state and one can invoke living will to let the healthcare provider know the wish of the patient when the patient is unable to communicate. The legal issues which will be faced by the committee is to ascertain whether the living will is genuine or not, whether the will is accordance with the state law which guide the will. In some states the format and language of the will should be as accordance to the format provided and in other states one can use own language too. There are more ethical implication in this case because no one knows when a person will be cured. Medical science have failed many times when people recover from extraordinary and terminally ill medical condition. The committee has to consult the family members of the patient and by use of living will and own consciousness to take a best interest decision for the patient.The hospital can after consulting carefully with eveyone remove the temporary pacemaker so that suffering to the patient will be less.

When the commitee will take a final decison by consuting the family members and the attorney can remove the pain medication. There will not be any such problem in removing pain medication when it will be decided that not to let the patient suffer more.

According to the living will, the patient has not given power to anyone to take decision on his behalf when he will be unconscious and terminally ill. By going through this clause we can say that wife have not the ability to overrule the Living will.

The commitee shoud recommend to the physician and family to implement the living will and let the patient die in peaceful measure.