Critical Care · Year 4 · from Critical Care
Case 2: Surrogate Decision-Making and Family Conflict
Clinical Image
Source: Wikimedia Commons - Medical Ethics - CC BY-SA 3.0
Case Presentation
A 67-year-old man with no advance directive suffers a massive intracerebral hemorrhage with a Glasgow Coma Score of 5. CT shows 60 mL of blood with midline shift and intraventricular extension. The neurosurgery team determines he is not a surgical candidate. His prognosis is very poor, with the ICH Score predicting greater than 90% mortality at 30 days. He has two adult children: his daughter, a nurse, recognizes the severity and believes her father would not want to be kept alive in this condition based on his comments about his mother's prolonged death. His son, who lives out of state and has not seen his father in years, insists on "doing everything" and threatens legal action if treatment is withdrawn. Neither sibling has healthcare power of attorney. The ICU team facilitates a family meeting where both children can share their perspectives. The daughter recounts specific statements their father made. The son acknowledges he did not know his father had expressed these views but struggles with guilt about their estrangement. The team explains that they are asking the children to speak for their father using substituted judgment, not to make their own preferences known. A chaplain provides spiritual support. Ethics consultation is obtained to help mediate. After 3 days of discussion and the patient developing fixed pupils, the son accepts that continued treatment is not what his father would have wanted. A unified decision is made to withdraw mechanical ventilation.
Key Learning Points
- Substituted judgment asks what the patient would decide, based on known values and prior statements; best interest standard applies only when wishes are truly unknown
- Surrogate hierarchy typically follows: designated healthcare proxy, spouse, adult children (requiring consensus), parents, siblings
- Family conflict often stems from different interpretations of patient values, guilt, grief, or different information about prognosis
- Ethics consultation can help mediate disagreements and provide structured analysis when conflicts persist