A 72-year-old gentleman with metastatic pancreatic cancer was admitted to the ICU with increased oxygen demand and confusion, likely related to pulmonary metastases. In the presence of his son, the healthcare agent, and the team, the patient requested to be do-not-attempt-resuscitation and do-not-intubate (DNR/DNI) before losing decision-making capacity. When the patient's brother and another son heard of the code status change, they insisted on a return to Full Code. Although the youngest son (the healthcare agent) was present for the patient's request to be DNR/DNI, he declined to represent the patient's wishes and agreed with a return to Full Code. Numerous discussions over subsequent days revolved around the attempt to honor the patient's wishes in the setting of the surrogate's unwillingness or inability to make decisions in alignment with his father's wishes. This case reviews and analyzes the ethical options available to the clinical team in responding to requests for potentially inappropriate treatment at a patient's end of life, and explores the roles of relational autonomy, beneficence vs nonmaleficence, and holding the balance of clinicians' and ethicists' professional, legal, and ethical responsibilities.

中文翻译：

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ICU 的临终伦理咨询：谁有最终决定权 - 患者还是家属？


一名 72 岁的转移性胰腺癌绅士因需氧量增加和意识模糊而入住 ICU，可能与肺转移有关。在他的儿子、医疗保健代理人和团队在场的情况下，患者要求在失去决策能力之前进行不尝试复苏和不插管 （DNR/DNI）。当患者的兄弟和另一个儿子听说代码状态发生变化时，他们坚持要恢复为完整代码。尽管最小的儿子（医疗保健代理人）在场接受了患者成为 DNR/DNI 的请求，但他拒绝代表患者的意愿并同意恢复完整代码。随后几天的大量讨论围绕着在代孕妈妈不愿意或无法根据父亲的意愿做出决定的情况下试图尊重患者的意愿展开。本案例回顾和分析了临床团队在响应患者生命末期可能不适当治疗请求时可用的道德选择，并探讨了关系自主、仁慈与非恶意的作用，以及保持临床医生和伦理学家的专业、法律和道德责任的平衡。