- Say What You Mean and Mean What You Say:A Patient's Conflicting Preferences for Care
LW, a sixty-seven-year-old woman suffering from ovarian cancer, has been sent from the rehabilitation facility where she lives to the emergency room for treatment of a small bowel obstruction. In the emergency room, LW directs that her husband of forty-two years make all medical decisions if she becomes incapacitated. She tells her admitting physician that she has no formal advance care directive and does not wish to limit any medical therapies, including cardiopulmonary resuscitation (CPR).
During her hospitalization, LW's cancer advances, causing recurrent bowel obstruction. Doctors perform palliative surgery, and afterward, LW cannot be weaned from mechanical ventilation. She soon develops kidney failure and needs regular dialysis. She also depends on intravenous medication to maintain her blood pressure. Remarkably, she remains alert and communicative.
More than two months into her hospital stay, LW's attending physician reviews each treatment with her, as well as her general condition (guarded) and her prognosis to survive (poor). LW wishes to continue all treatments since they allow her to enjoy daily visits with her family. Her doctor supports this wish, but he informs her that she is at risk for cardiac arrest and, should she suffer it, her chances of surviving are remote. He fears CPR would cause needless suffering during her last moments of life.
LW accepts her physician's assessment and agrees that she doesn't want CPR. However, she seems reluctant to agree to a formal do-not-resuscitate (DNR) order, so two days later, he asks her again. She again states that she does not want to be resuscitated. Her doctor then asks her husband to discuss her preference with her, but when he does so, she denies ever saying that she doesn't want to be resuscitated.
The next day, LW tells her puzzled doctor that she lied to her husband to ease his pain—she believed he would object to a DNR order and so assumed a request for one would only magnify his anguish. Her doctor tells LW's husband this privately, hoping he will drop his objection to a DNR order, but he still wants CPR attempted even knowing she doesn't. He says he can't let her go and is willing to take any chance to prolong her life, even briefly.
Several days later, LW develops cardiac arrest. Should her physician attempt CPR?
Normative practice calls for physicians to treat patients according to their wishes. Since it appears that LW's most rational preference was to avoid the trauma of CPR, her physicians would violate this norm by attempting resuscitation. However, it is not clear whether LW's most authentic preference was to avoid CPR or to tend to her husband's needs.
Patients, when developing their preferences for treatment, often consider a series of complex social, emotional, and existential concerns. To downscale this complexity, clinicians often solicit from their patients narrow, simplified, medicalized treatment preferences, viewing patients' decisions as less legitimate if they take into account broader concerns such as family needs. But are one's wishes less authentic or more authentic when considerations of family interests are subtracted from the discussion? For many patients, their family interests are self-interests.
"What the patient wants" is often understood as "what the patient wants for him or herself, assuming he or she has no concerns regarding the effects of the decision on people near and dear." Yet while it is tidier for clinicians to view patients as socially unencumbered individuals, many patients define themselves significantly—even primarily—in terms of family. The distinction between patients' self interests and patients' family interests is largely artificial—most of us live within some form of intimate social structure. Our lives are filled with compromises and sacrifices for people for whom we care deeply. We sacrifice financially for our children, we dedicate time to our elderly parents and friends in need, and we forego opportunities for individual enjoyment and benefit for our families' good. We do these things willingly and [End Page 14] often quite lovingly. Our choices not only help people...