By Charles A. Pilcher MD FACEP
Your 88 year old mother has just been admitted to the ER with a severe stroke. The doctor comes out of the resuscitation room, explains the gravity of the situation, and says that because of brain swelling, an endotracheal tube and artificial ventilation is needed. He asks for your consent to do the procedure.
“And what will happen if we don’t do anything?” you ask.
“Well, she is already gravely ill, with pressure building up in her brain. If we do nothing, there is a high probability that she will stop breathing and die,” he responds.
“And if we go ahead with the procedure?” you ask.
“Again, there’s no promises here, but it’s the best thing we can do for her at this point” replies the doctor.
You agree to the procedure and sign a consent form authorizing the doctor to proceed, knowing that your mother had a living will, but being unwilling to invoke it yet without giving her at least a chance to recover.
After a few days she does not improve, remains comatose and is not breathing on her own. The staff calls a family conference to discuss “pulling the plug.”
Admittedly, there’s a lot lacking in the above scenario, but it begs the question: Does consenting to a lifesaving procedure commit the authorizing party forever? If the authorizing party can consent to a lifesaving procedure, does that person at a later point have the right to withdraw his/her consent?
Medicine, law and ethics struggle over these issues regularly. We debate and worry about “pulling the plug,” often unnecessarily. Perhaps we should focus more on who had the authority to “put the plug in” in the first place, go back to that person and say, “The situation has now changed. Given what we know now, the procedure which was performed [or to which you gave your consent] has not had the desired outcome. It didn’t work as we thought it might.”
Since the person giving consent had the right NOT to authorize the procedure and to allow death to occur naturally, can that person now withdraw consent when death is more likely to occur? Although it is a fine line, instead of now authorizing medical personnel to ‘pull the plug,” would it make more sense to allow the consenter to just withdraw consent for the procedure, given current facts?
In this writer’s opinion, any lifesaving intervention that is done on a trial or temporary basis, such as blood transfusions, antibiotics, intubation/ventilation, dialysis, cardiac pacing, IV fluids, artificial feeding, etc., should come with a “retraction clause” that states “Should circumstances change or the procedure not have the desired effect, I reserve the right to withdraw this consent at any time.”
The end result would be the same, but the person giving consent – whether the patient or a surrogate – thereby retains control and acknowledges up front his or her role in the care and medical interventions.
Perhaps such an approach would be more proactive than asking if families want to “pull the plug.”
Editor’s Note: I highly recommend that all attorneys involved in estate planning, living wills and advanced directives familiarize themselves with two resources. One is Washington State’s “Physician Orders for Life-Sustaining Treatment” (POLST) form. The other is a booklet called “Hard Choices for Loving People” that explains in lay language the advantages and disadvantages of various end-of-life interventions. I can provide copies of both if you email me.