Legal Medical Decision Making in Nonterminal Conditions: The Intersection of Ethics, Law and Patient Autonomy

Outcomes 1. Apply legal understanding of the role of medical decision makers at the end of life. 2. Navigate ethical principle to provide high quality palliative care to patients at the end of life. Key Message In the state of Pennsylvania, a default surrogate decision maker may not withdraw medical care under nonterminal conditions. Decision making for a medical power of attorney is not limited to end-of-life conditions. It is crucial to understand the different scopes of decision-making authority granted to substitute health care decision makers. Background There are many forms of surrogate decision makers within the health care system [1]. In the United States, state law determines limitations on surrogate decision makers depending on whether the surrogate is chosen by default or is formally designated by the patient [2,3]. Within the state of Pennsylvania, default decision makers cannot withdraw life-sustaining treatment under nonterminal conditions, whereas patient-designated health care proxies can. Case Description Mr. J.C. is an 81-year-old man with extensive vascular comorbidities, alcohol use disorder, MDD, and PTSD who presented following an unwitnessed fall at home and was found to have an unstable C5/C6 fracture and right globe rupture complicated by right orbital floor and maxillary sinus fractures. Following C5-C7 decompression and C3-T1 fusion, the patient was intubated for altered mental status and an inability to protect his airway. A subsequent family meeting with his wife and daughter, both of whom held medical power of attorney, revealed that the patient was a former Army Colonel who struggled transitioning back to civilian life, using alcohol to cope with PTSD and depression. The family expressed that despite clinical improvement, he would not want rehab or returning to his prior life and they for palliative extubation, and the patient died shortly thereafter. These decisions were met with much distress from primary team prompting intervention by palliative care and hospital ethics. Conclusion Understanding of the rights of varying decision makers is essential in providing high quality palliative care. Surrogate decision makers are unable to withdraw life-sustaining treatment in the setting of nonterminal conditions. However, medical powers of attorney can make medical decisions on behalf of someone if the individual cannot make those decisions for themselves, regardless of whether the condition is terminal. Knowledge of the surrogacy and medical decision maker law is essential in preventing conflict amongst medical team. Keywords Ethical / Legal Aspects of Care; Shared Decision Making / Advance Care Planning