The role of family surrogates in providing a voice for
incapacitated patients is of crucial importance. Usually, surrogates have the
best interests of the patient in mind and try to work with the physician in
charge to provide the best treatment possible for the patient. In most cases
there is agreement between the surrogate and the physician about the treatment
plan and the goals of care. But as those of us who do clinical ethics
consultations know, there are some cases, maybe 5% or fewer, where there are
serious conflicts between surrogates of patients lacking capacity and
physicians. I want to briefly explore a type of conflict that we seem to be
seeing more often—when the surrogate attempts to get too involved in the
medical management of the patient. Let me use a couple of sample cases to
illustrate the type of conflict I have in mind.
The first is the case of an elderly patient with dementia
and with multiple medical problems, including severe pressure ulcers. This
patient requires regular dressing changes for the pressure ulcers in order to
keep them clean and well managed, requiring the patient to be turned, which
causes her significant discomfort. When these dressing changes happen, the
standard of care is to make sure the patient suffers as little as possible, so
a small amount of morphine is given. But the family surrogate informed the
nurse that she should not use morphine, as she wanted the patient to remain as
alert as possible at all times. When the nurse tries to perform the dressing
changes without giving morphine the patient groans, grimaces, and appears
agitated and in pain.
The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.