To The Editor:
We applaud the introduction of the new section "Ethics
in Practice," but we question the conclusions reached by Capozzi
and Rhodes in the case of H.K. (82-A: 748-9, May 2000). A surrogate is
presumed to be responsible for protection of the patient’s
best interests. Surrogates are often family members (as in the case
of H.K.), who typically have known the patient for a long period
of time. While it would be ideal if a patient and the surrogate
had had a prior discussion on every possible medical problem that
might arise in the future, this is clearly impractical. The burden
then rests on the surrogate to make a "substituted judgment," on
the basis of knowledge of how the patient led his or her life and
personal discussions with the patient, including any comments that
the patient may have made about the health-care decisions of others.
When a patient has the capacity to make a decision, we must respect
the patient’s autonomy, even if we believe that the decision
may result in his or her death or the loss of a limb. It is also
our responsibility to respect the decision of the surrogate, even
if we believe it is the wrong decision. A surrogate’s decision should
prevail in the absence of clear evidence that it is contrary to
what the patient would have chosen were he or she still capable.
If the decision of a surrogate is patently contrary to the patient’s
best interests, this alone is not sufficient to void the surrogate’s
decision, but careful investigation of the patient’s pre-expressed
wishes, beliefs, and personal philosophies may be indicated. Even
more important, in this case, the surrogate’s decision
does not even approach that threshold.
In the case of H.K., we don’t believe that the medical
literature would support the medical conclusion reached by the authors1,2. Nonoperative treatment of hip
fractures in nonambulatory patients can be accomplished successfully,
along with pain control and the prevention of complications associated
with bed rest. For a patient with dementia, standing orders for
pain medication should be instituted initially and then the dosage
should be tapered over a period of one to two weeks, in accordance
with the patient’s need as reported by the staff. A patient with
a hip fracture should be mobilized immediately, with use of a sliding board
for transfer to a reclining chair where the patient can be placed
in the most upright position that is tolerable. In a large percentage
of patients, the fracture pain resolves within a short period of
time, and the preinjury level of mobility is readily resumed.
H.K. is clearly entering the latest stage of her life. Irrespective
of medical intervention, she will never become a fully oriented,
independently functioning individual. It is imperative that, after the
family has made a judgment based on the medical information that
has been explained to them, we support their decision. We can accomplish
this by giving them the psychological support that they need after
making a heart-wrenching decision, and we should honor the patient’s
autonomy also by treating him or her as directed and preventing
suffering.
J.D. Capozzi and R. Rhodes reply:
We appreciate Dr. Levin’s and Dr. Williams’ letter
regarding the issue of surrogacy. When we first proposed an ethics section
for The Journal, it was with the hope and understanding that these
case studies would provoke discussion and some controversy about
bioethical issues in orthopaedics. With regard to this particular
case, we would like to make two points.
It has been our experience, in our geriatric hip-fracture service
at Mount Sinai Medical Center, that intracapsular hip fractures
can indeed be treated nonoperatively when the need arises. If a patient
is unable or unwilling to proceed with the surgical treatment of
a femoral neck fracture, nonoperative treatment can be pursued,
although this is not an ideal situation. However, our results with
the nonoperative treatment of displaced intertrochanteric fractures have
been poor. We have found that controlling pain is exceedingly difficult,
skin breakdown is more common, and nursing care is less than optimum due
to the difficulty of moving these patients. Our experience has been
that even high-risk patients fare better with open treatment than
they do with nonoperative treatment for these particular fractures.
Additionally, although this particular patient presented with
a hip fracture, the point that we were trying to make in the article
was that there are situations in which physicians can justifiably override
the decisions of surrogates. Maybe another example—an open
fracture or impending sepsis—would have better made the
point.
We do agree with Dr. Levin and Dr. Williams that physicians should
do everything possible to honor and support the heart-wrenching
decisions that surrogates must often make. We have rarely, if ever,
contradicted a surrogate’s decision. However, we must keep in
mind that, as physicians, our primary responsibility is to our patients,
and that responsibility may, on rare occasions, require overriding
the decision of a surrogate.