A 69-year-old woman is transported to the emergency department by emergency medical services after a fall in a nursing home facility. She is accompanied by several family members who report a history of severe Alzheimer dementia. She has had several recent falls which required emergency department visits and a near-fatal bout of pneumonia two months ago which required a prolonged hospitalization. During the most recent inpatient stay, her son who is her healthcare power of attorney signed documents for do not resuscitate (DNR) and do not intubate (DNI) orders in the event of a cardiac or respiratory arrest. On physical examination, she is noted to be obtunded and then goes into cardiac arrest. She has no palpable pulses, and her respirations are irregular. Her daughter and grandson ask the medical staff to begin cardiopulmonary resuscitation (CPR).
Which of the following is the most appropriate action by the medical staff?
- A) Consult the critical care team to begin cardiopulmonary resuscitation
- B) Consult the hospital ethics committee for recommendations
- C) Do not pursue intubation or resuscitation efforts
- D) Intubate the patient and begin chest compressions and mechanical ventilation
- E) Obtain a court order to intubate and resuscitate the patient
C) Do not pursue intubation or resuscitation efforts
During the patient's previous stay in the hospital, do not intubate (DNI) and do not resuscitate (DNR) orders were placed by the son who is the patient’s healthcare power of attorney. In this case, the patient's son acts as the healthcare proxy because the patient not only has severe Alzheimer disease but is also unresponsive and is thus lacking decision-making ability. In this case, healthcare power of attorney has already been determined legally and ventilation and cardiopulmonary resuscitation have been declined due to the patient’s progressively worsening health status. A court order would not change the decision-making and would not be obtained quickly enough to intervene in this situation.
Key Learning Point
Surrogate decision-makers who have healthcare (also known as durable) power of attorney status have the right to refuse care on behalf of a patient who does not have decision-making capacity.