How would these new approaches affect both ethical reasoning and communication with surrogates? This can be best illustrated with a case:
A 76-year-old woman is admitted to the intensive care unit for pneumonia. She develops sepsis with renal failure and a rising potassium level. Her physicians approach her son to discuss whether to initiate dialysis or change the focus to palliative care and comfort. Her son says, “My mother was always a fighter. She wouldn’t want to give up.” The patient does not have advance directives.
Under the traditional framework, the physician would first inquire about the patient’s wishes, with questions such as, “If she were able to be part of this conversation, what do you thing she would want to do?” It is consistent with the traditional substituted approach to explore the strength of evidence for the patient’s wishes. Did she ever make specific statements about intensive care, dialysis, or her preferences for the time and place of her death?
Using a community based approach, physicians would describe the treatment options that had previously been determined to be acceptable under the circumstances. Physicians may say, “When a person such as your mother develops kidney failure, our hospital and health care system offer comfort care. We would not attempt to resuscitate her if her heart or breathing were to stop.” Such an approach sets limits on care, and decreases the range of options offered to the surrogate.
An approach based on respect for persons would focus on several aspects of the patient as a person, including prior wishes, her dignity, and her place in her family and community. This shift in focus would change the approach that physicians take to the conversation. Using narrative techniques, the family may first be asked to talk about the patient’s life and how this illness was a part of that life story. This approach allows a deep exploration of statements such as, “Mother was always a fighter.” However, because the conditions she is currently facing may be different from any she had encountered, her prior approach to life cannot be assumed to tell us what she would do under the present circumstances.
The process of recounting the patient’s life can build a common purpose and understanding among surrogates and health care providers.50
It retains the psychological advantage of turning attention from the needs and wishes of the patient’s loved one’s to those of the patient, but maintains a realistic perspective on what we can know about the patient.
A potential limitation of the narrative approach is that it does not provide a clear mechanism for resolving disagreements. There is no objective scale for judging one family member’s narrative as superior to another’s. However, we argue that in most cases, this approach will lead to consensus about the right course of action and will decrease the need for choosing one surrogate over another. When this approach fails, a last resort is the legalistic approach of giving decision making authority to one surrogate over the objections of others. Many state laws specify such a hierarchy.