What is the appropriate plan of care for this seriously ill patient?

An elderly patient was unconscious in an ICU. According to the treatment team, her prognosis was poor. Most jurisdictions have a legal hierarchy for determining a patient’s appropriate substitute decision-maker. In this case, because the patient did not have a power of attorney or spouse, next on the hierarchy was a majority of the patient’s adult children. Unfortunately, in this case, the patient had thirteen adult children, which meant that the consent of seven would be necessary for any treatment. 

Also unfortunately, there was significant disagreement among the children about what the best plan of care was. The ICU team felt that switching to comfort care was most appropriate, since the patient was unlikely to meaningfully improve or even regain consciousness. Some of her children agreed with the treatment team, while others thought that aggressive, life-sustaining treatment was worthwhile. 

The clinical ethicist serves two main functions in this case. First, the treatment team was unsure whether continued aggressive treatment, including keeping her full code— performing chest compressions and intubation if her heart stopped—was ethically acceptable. They also did not want to rush the family. The ethicist was in regular communication with the team to help them navigate this difficult situation. 

The ethicist also played a central role in working with the family to find common ground. At least two of the siblings would not speak to each other. Others were not sure what their mother would have chosen for herself. The ethicist met with the siblings individually and in groups to determine the best plan of care.