You are an intensive care unit physician. One of your patients is a 63-year-old woman, previously high functioning, who has suffered a MASSIVE HAEMMORRHAGIC STROKE. She has been intubated and mechanically ventilated for 14 days. She has intact brainstem reflexes but is not rousable or responsive to external stimuli. Three consulting neurologists at your institution have determined that the probability of an improvement in the patient's clinical status is very low or zero. The patient's husband, who is the sole SDM, requests ongoing mechanical ventilation, saying this is in keeping with his wife's religious beliefs. He maintains this position after extensive discussion with the medical team, religious advisors and the hospital ethics committee. From each column, select the option that best approximates your most likely management plan in this scenario. | |||
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BEFORE the Rasouli decision | AFTER the Rasouli decision | Most Medically Appropriate* | |
Provide mechanical ventilation until the patient's SDM consents to withdraw life support. DTI score*=2/2 | □ | □ | □ |
Inform the patient's SDM that you intend to withdraw life support and inform him of his option to pursue a legal injunction to prevent you from doing so. If he does not pursue this option, withdraw mechanical ventilation and provide comfort measures. DTI score=0/2 | □ | □ | □ |
Appeal to the Consent and Capacity Board (in Ontario) or the courts (other provinces) for consent to withdraw life support, arguing that ongoing mechanical ventilation is not in the patient's best interests. DTI score=1/2 | □ | □ | □ |
*Calculating DTI score and subjective appropriateness score: For BEFORE SCC decision and AFTER SCC decision columns, DTI scores (0–2) are assigned and pooled scores for all five vignettes (0–10) are calculated. BEFORE and AFTER columns are assigned a subjective appropriateness score of 1 if they correspond with the respondent's own definition of the most medically appropriate plan and 0 if they do not. Pooled subjective appropriateness scores for vignettes 1–5 range from 0–5.
DTI, degree of treatment intensity; SDM, substitute decision maker.