Discussion 05.4: Living Will

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 in 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.

  1. 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?
  2. Are there any problems in removing the pain medications (the patient’s comfort care)—if so, what are they?
  3. Should the wife have the ability to overrule the Living Will? Does she have that ability?
  4. What recommendation should the committee ultimately make to the physician and/or the family?

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