A 51‐year‐old man with a history of depression and both oral hyperesthesia and stroke suffered during a recent dental procedure was admitted for profound weight loss, malnutrition, and constipation. During admission, he consistently refused both oral and parenteral nutrition. Because of the patient's aphasia and mild cognitive impairment from his stroke, there was no way to competently assess his decision‐making capacity. Both psychiatry and ethics were consulted and provided conflicting recommendations. Psychiatry believed that depression could not be ruled out, was unsure of the patient's decision‐making capacity, and recommended feeding the patient by any means. Ethics thought that the patient's consistency in refusing to be fed would make force‐feeding him equivalent to assault and thus recommended not feeding him. Because of the patient's increasingly rapid clinical decline, the oncoming hospitalist was required to make a decision about whether or not to feed the patient on the first day of clinical service. On this day, the patient was increasingly lethargic with borderline hypotension, glucose 20, potassium 3.1, magnesium 1.3, and calcium 6.5. Given the ambiguity of the patient's desires, conflicting wishes of the family, and the hospitalist's lack of familiarity with the patient's complicated psychosocial issues, this presented the hospitalist with a difficult and uncertain decision. Ultimately, the hospitalist chose not to feed the patient, and the patient died the next day.
In this case, the patient's decision‐making capacity was unclear. Although it was impossible to assess if he understood his situation and the consequences of his decision not to eat or if he was depressed, he was very consistent over time in refusing feedings. The patient did not have an advanced directive or durable power of attorney, and his family relationships were conflicted, making it unlikely that a family member might accurately represent his wishes. Thus, the hospitalist was left to decide by making a substituted judgment. In cases of substituted judgment, the guiding principles include beneficence, nonmaleficence, and autonomy. Because of the patient's unclear wishes, it was difficult to determine what would constitute beneficence in his case. For this reason, the principles of nonmaleficence and autonomy provided guidance. Feeding the patient might prolong his suffering, both physically and emotionally. Not feeding him would result in almost certain death. The hospitalist did not wish to physically force an undesired intervention on the patient and wished to respect his autonomy by honoring his consistent refusal to be fed.
Hospitalists frequently encounter complex ethical decision‐making dilemmas. Understanding and applying the criteria for determining decision‐making capacity and the principles of beneficence, nonmalfeasance, and autonomy can aid in making these challenging choices.
H. Whelan ‐ none
To cite this abstract:Whelan H. Decision‐Making in the Face of Ethical Uncertainty. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 430. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/decisionmaking-in-the-face-of-ethical-uncertainty/. Accessed April 5, 2020.