Question

Scenario: You are a hospital administrator who has been told by your ICU unit director of a patient in the unit who has suffered serious brain damage from a car accident 2 days ago and is currently intubated. The patient is 45 years old but does not currently meet the criteria for complete brain death as defined by Arizona state legislature "4-1107. Determination of Death and Status; Rules." The spouse of the patient has consulted with the attending physician.

The attending physician informed the spouse that the patient could survive but would likely require life support. Half of the family is insisting that the patient "wouldn't want to live this way" and the other half is accusing the other family members of wanting to "kill" the patient.

Some allegations have been raised about a substantial inheritance for some family members upon the patient's death. The battle is becoming intense, and it is beginning to disrupt the medical and nursing staff. Describe the medical care issues involved in this situation. Explain which laws and regulations apply to this situation. How would you interpret these laws and regulations when making a decision? Describe the ethical issues that may arise based on your decision as the administrator.

Explain how you can ensure appropriate implementation of supporting policies and procedures in order to ensure ethical integrity. What policies and procedures would you consider when making your decision? How would you ensure these procedures were followed correctly? What resources could you use to support your decision?

Answer 1

1. a) The medical care issues involved in this situation are:

• Emergency decision making.
• Providing any required and possible emergency care before placing the patient on life support.
• Advising/educating the family regarding criteria for complete brain death as defined by Arizona state legislature "14-1107. Determination of Death and Status; Rules" and other applicable rules.
• Providing life support ASAP with the family's consent.

b) Laws and regulations applicable to this situation are:

i) Rules of evidence in courts of general jurisdiction.

ii) Arizona state legislature "14-1107. Determination of Death and Status; Rules" quoted below:

• 1. A determination of death must be made in accordance with accepted medical standards.

• 2. A certified or authenticated copy of a death certificate purporting to be issued by an official or agency of the place where the death purportedly occurred is prima facie evidence of the fact, place, date and time of death and the identity of the decedent.
• 3. A certified or authenticated copy of any record or report of a governmental agency, domestic or foreign, that a person is missing, detained, dead or alive is prima facie evidence of the status and of the dates, circumstances and places disclosed by the record or report.
• 4. In the absence of prima facie evidence of death under paragraph 2 or 3, the fact of death may be established by clear and convincing evidence, including circumstantial evidence.

iii) Uniform Determination of Death Act:

Adopted by all 50 states, states the neurological criteria for determining death.  This law describes total brain death or the irreversible termination of functions of the brain, including the brain stem, as valid criteria for death.

c) Interpretation of the above laws and regulations when making a decision:

• The above laws and regulations point to the fact that brain death criteria should be met for the patient to be considered as dead. The determination of death should be made in accordance with accepted medical standards. The neurological criteria for determining death as per the Uniform Determination of Death Act should be followed.

d) Ethical issues that may arise based on the decision made as the administrator:

• Balancing the necessity for medical accuracy with ethical principles consistent with respect for the inviolable and inherent dignity of the human being.
• Clarity in policy based on medical ethics.
• Rebuild trust regarding ethical criteria for the determination of death.
• Building the gap between medical professionals and family members.