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.
PH is a 50-year-old female admitted with progressive reversible encephalopathy syndrome (PRES). She is unresponsive with a Glasgow Coma Score of 6 (withdraws from noxious stimuli only), and palliative medicine was consulted to discuss scope of treatment. PH has 2 young children at home who are being cared for by her sister. Her 2 other sisters are in the room and state PH's husband has a restraining order against him for physical abuse but that he wants to make decisions on her behalf. They state they have documentation of the restraining order, but refuse to show it to the consultant because they are ''afraid of what the husband would do'' if he found out other people knew about the document. They feel he would not be an appropriate surrogate and would not have PH's best interests in mind. On the other hand, they are unwilling to confront him or apply for guardianship. The palliative medicine team does not have independent verification of the restraining order, and the husband is on his way to the hospital. An emergency ethics consult is requested.
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