Cardiac Interventions In The Absence Of Assent: An Ethical Dilemma

Cardiac Interventions In The Absence Of Assent: An Ethical Dilemma
Complex Clinical Cases
Cooper B. Kersey, Beteal Ashinne, Jeffrey Keenan, James N. Kirkpatrick
Journal of the American College of Cardiology, March 2023
Open Access
Cardiovascular practitioners increasingly encounter complex treatment decisions, further complicated when patient decisional-capacity is impaired. We present an ethical conundrum of a patient without decision-making capacity who declined a life-saving surgery.
A 63-year-old woman with schizophrenia and a prior history of mitral and aortic valve endocarditis was found to have recurrent endocarditis of her bioprosthetic mitral valve. Surgical management was recommended, but the patient declined. During a formal capacity assessment, the patient was deemed unable to comprehend her medical condition or the consequences of refusing surgery. The patient then developed transient complete heart block. Goals of care discussions revealed that the patient valued life prolongation and amelioration of her symptoms.
The patient’s durable power of attorney gave consent to proceed with the surgery. Surrogate decision-making rests on substituted judgement (based on knowledge of what the patient would have wanted) or best interest standards (based on beneficence or non-maleficence). The hospital ethics team supported the decision to proceed with surgery over the objections of the patient, in light of the prognosis without surgery, the likelihood of surgical benefit, and the values and goals the patient espoused. The ethics consult team also recommended seeking assent for the surgery from the patient. Assent is not required in addition to consent from a surrogate, but it oftentimes facilitates interventions without chemical or physical restraints. Ultimately, the patient provided passive assent and underwent successful re-do mitral and aortic valve replacements and was discharged in stable condition.
We highlight a case in which cardiovascular clinicians encountered a patient without decision-making capacity refusing a life-saving intervention. Cardiovascular clinicians should be familiar with important ethical elements involved in complex decision-making, including autonomy and its limits, substituted judgement and best interests standards, and standards and laws pertaining to surrogate decision-makers.

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