Objectives

1. Explain the concept and moral foundations of surrogate decision-making.

2. Describe the ethical and legal criteria for choosing a surrogate and for surrogatedecision-making.

3. Identify classic ethical dilemmas of surrogate decision-making, for example:family stake in treatment decisions, reliability of surrogate decision-makers,potential conlicts between possible surrogates, and between surrogates and careproviders.

Case

Mr. D was a 57-year-old man with a history of schizoaffective disorder and drug abuse whopresented to the emergency department with a diffuse painful maculopapular rash, blisteringof his mouth, sloughing of skin at the tip of his nose and a temperature of 104 degrees.He required urgent intubation due to extensive oropharyngeal involvement and an increasingoxygen requirement in the emergency department. He was admitted to the burn intensive careunit and diagnosed with drug-induced toxic epidermal necrolysis caused by a new psychiatricmedication that was begun severalweeks prior to his presentation. His rash involved 95 percentof his body including his mucous membranes and his eyes.

His hospital course was complicated bywound infection, sepsis requiring pressors, hypotension,acute renal failure, and severe pain, particularly with dressing changes. He had a prolongedstay in the intensive care unit and remained ventilator dependent. His prognosis basedon his presentation, including the extent of skin involvement and subsequent complications,was poor. His mortality was estimated at greater than 75 percent and, even if he survived a severalmonth intensive care unit stay, he would require a lengthy, painful rehabilitation courseand likely lifelong assistance with care either at a facility or with care providers in his home.