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a Department of Surgery, Duke University Medical Center, Box 3496, Duke South Room 3589, Durham, NC 27710
b Division of Thoracic Surgery, University of Maryland Medical Systems, Baltimore, MD
c Surgicenter of Baltimore, 3519 Barton Oaks Rd, Baltimore, MD 21208
d Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 409, Charleston, SC 29425
(Email: damic001{at}mc.duke.edu; sader{at}musc.edu).
We appreciate Dr Prager's [1] insights and comments on our debate regarding the appropriateness of heroic measures and the role of surrogates in making end-of-life decisions [2]. Although Prager [1] correctly points out that some states, such as New York, use the "clear and convincing" standard of evidence for documenting a patient's end-of-life wishes in the absence of a written advance directive, many other states use the "preponderance of evidence" standard mentioned in the concluding remarks section. Laws and their application by courts differ from state to state, leading to variation in legal delineation of surrogate decision-making power, but the ethical obligation of physicians is clearly stated in the American Medical Association's Code of Medical Ethics stating: "Physicians should recognize the proxy or surrogate as an extension of the patient, entitled to the same respect as a competent patient" [3].
Prager [1] raises the question of whether dialysis is a heroic measure, but it is important to recognize that the surgeon's answer to this question is not relevant. Mr Cooper must answer it, and the only way he can do so at this point is through his wife's understanding of his values and viewpoint. The questions of fact that Prager [1] also raises are issues for the wife to consider as she attempts to interpret what her husband's wishes would have been under the circumstances.
It is true, as Prager [1] states, that the question of whether the wife's judgment is correct can not be answered considering only the information provided in the introductory scenario. However, this question is the crux of Dr Ashley's dilemma, and he must answer it as best he can. Therefore, if additional information is needed, he should take the steps to obtain it. The surgeon's primary obligation in determining whether to take the case to probate court is to decide whether Mrs Cooper's judgment about her husband's authentic values and wishes is substantially correct or not [4].
Prager [1] is correct in stating that substituted judgment is often inaccurate [5], but the judgment of a close family member, such as the wife who has lived with her husband for many years, is likely to be far more accurate than that of the physician who has patient relatively briefly known the patient [6].
We completely agree with the idea that a patient-designated agent provides the best solution to difficult scenarios such as the one presented. Such an agent, unfortunately, was not available in this case.
The suggestion that Dr Ashley could look for a colleague to accept transfer of the patient is valid. The surgical ethics of responsibility for one's own patient, however, is powerful, and we believe that this option would rarely, if ever, be undertaken by a surgeon who has just operated on a patient.
Prager [1] has made a valuable contribution to this discussion and we are grateful for his thoughtful comments.
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