Case Study: Substitute decision-making
Vivian is an 85-year-old resident of the Sapphire Peaks Nursing Home. She is generally well although she suffers from Type 2 Diabetes. While showering recently, she accidentally scratched her lower leg. The scratch is quite deep and the skin has had trouble healing. A few days later the scratch has become infected. Vivian decides it will heal soon and doesn’t mention it to the nurses as she doesn’t want to bother them.
A few days later, the nurses find Vivian in bed confused, disoriented and having trouble breathing. They discover the scratch, which has become gangrenous, causing Vivian to suffer septic shock. An ambulance takes Vivian to the hospital emergency department where specialists determine she needs an urgent amputation below the knee to prevent the further spread of infection.
Vivian has lost capacity and she does not have an Advance Care Directive. The doctors consult with Vivian’s family and friends, who have arrived at the hospital. Present are Amy, Vivian’s daughter, and Vivian’s ex-husband (and Amy’s father), Robert. Vivian’s life-long friend Irene is also there.
The specialist team advises the group that a treatment decision about the amputation needs to be made urgently if they are to save Vivian’s life. They also advise that the procedure is extremely invasive and there is a medium-level risk that given Vivian’s age she may not come out of the anaesthetic, but they are prepared to proceed with a substitute decision-maker’s consent.
The group discuss whether Vivian should have the operation. Amy recalls that Vivian had previously told them that she would never want to have a major operation or medical treatment at this stage in her life. Vivian had also said that if she was dying she didn’t want to be kept alive. Amy does not want to go against her mother’s wishes, and though she is devastated she reluctantly tells the doctors not to operate.
Robert and Irene are horrified. Irene can’t bear the thought of Vivian dying if there is a chance she might survive. Robert agrees. Though he and Vivian are not on the best terms, he still cares about her and wants her to have the operation.
The specialists are aware that Amy is the legal substitute decision-maker. Robert cannot make the decision as he is no longer Vivian’s husband and does not have a close relationship with her. As Vivian’s daughter, Amy is the highest in the order of priority of decision-makers. Irene is a close friend, but is below Amy in the order of available decision-makers. It is therefore lawful for the doctors to rely on Amy’s decision not to operate.