SR is a 40-year-old male with severe trisomy 21; he has lived in a ''group home'' for the last 20 years and recently presented with pyrosis refractory to omeprazole. After referral to a gastroenterologist, a distal esophageal mass was discovered and was eventually diagnosed as stage I esophageal cancer. The brother and the group home administrator accompanied SR to his appointments and the decision for surgery was made. The surgery team felt that this was a potentially curable condition and also stated that the convalescent period would be long, and the risk of postoperative complication was significant. On the day of the planned surgery, the patient's brother called the hospital stating that the family had decided that SR was to be ''left alone'' and threatened litigation if surgery was performed. The surgery was deferred, but the group home administrator then called the hospital also threatening litigation if the surgery was not performed. Upon further investigation, the group home stated that the brother only visited SR once or twice a year and also alleged that the family simply wanted ''their part of his estate.'' The group home stated that SR had been making his own decisions and never had a power of attorney or guardian appointed. A psychiatric evaluation demonstrated that SR ''lacked the ability to understand information about his treatment, could not express the consequences of his choices, and could not make decisions on his own.'' The psychiatrist also felt that it was unlikely that this was chronic. An ethics consult was requested by the surgical team.
SP is a 52-year-old male who had an out-of-hospital cardiac arrest 10 days ago. He was found by his wife unconscious on the floor after an unknown amount of time. She provided cardiopulmonary resuscitation for 15 minutes until emergency medical services arrived. The initial rhythm was fine ventricular fibrillation and a stable rhythm with pulse was obtained after 10 minutes of advanced cardiac life support. He was transported to the local tertiary care hospital and hypothermia was provided. After rewarming for 24 hours, SP had a Glasgow Coma Scale of 3 (totally unresponsive). Despite a prolonged discussion of prognosis in anoxic brain injury, the patient's wife and children advocated aggressive treatment stating ''we're expecting a miracle to happen.'' An electroencephalogram (EEG) done yesterday showed no significant brain activity. Today, the medical team performed an apnea test on SP, which showed a 20-mm Hg increase in PCO 2 , supporting a diagnosis of brain death. A follow-up radionuclide cerebral flow study confirmed the diagnosis of brain death. The palliative medicine team discussed the results of the brain death determination at length with the family, who threatened to sue the hospital if SP was taken off life support, arguing that people recover from comas and that removing him from life support would be ''tantamount to murder.'' Risk management recommended deferring any withdrawal of medical treatment. Multiple discussions with the family had the same result and an ethics consult was requested.
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