Abstract

In lieu of an abstract, here is a brief excerpt of the content:UnbefriendedJean Watson“Can you be a friend to someone who needs one right now?”That probably wasn’t the question that our hospital clinical ethicist asked, though that is what I recall. It sounded like something my mother would encourage me to do. It sounded like something I would like to do. It sounded easy. It was none of that and so much more.Two weeks earlier, a man was found down in his apartment, unresponsive. He had had a stroke. He was hospitalized in our ICU on a ventilator. He had no family or friends to speak on his behalf. Decisions needed to be made. Should he undergo surgery to place a tracheostomy and feeding tube to continue his life?The hospital hired a private investigator who performed yeoman’s work, trying to find someone who knew this man, someone who might be able to share information about his values so that we could act in accord with them. Remarkably, no one was found. The patient had been retired from work for more than a decade. Though he rented an apartment, his landlord did not know him. No family was discovered. No friends came forward nor were identified. No medical records were uncovered. He had not seen a doctor or visited a clinic or hospital in the area until now. He was a solitary person, a human being without close relationships. His apartment was unkempt; beer bottles were strewn about the place.The clinical team requested an ethics consultation. Though the hospital does not have a formal policy for decision making at moments like these, our ethicist is well-versed in a variety of ways these circumstances are handled. Sometimes a treating physician functions as both the attending and a surrogate. This can be fraught with potential conflicts of interest. Unconscious bias could influence one’s thoughts about the value of a life and the cost to sustain it. Sometimes the attending provider presses on with therapies regardless of the likelihood of successful treatment. This choice fails to acknowledge individual autonomy. It fails to weigh the suffering required to live another day. It sidesteps the thorny issues that are discussed everyday between providers, patients, and loved ones.The ethicist gathered a group to serve as informal surrogates for this patient. Three of us agreed to act as friends and decision makers for this man, helping the treatment team determine next steps. The ethicist provided a few rules and much oversight.We met for a family conference. The intensivist and neurologist shared the diagnosis and treatment that the patient had received. They detailed information about the decisions that needed to be made. The patient’s nurse, the social worker, and the spiritual care intern attended the meeting to watch the proceedings and contribute to the discussion. We three, the patient’s friend group, were invited to ask questions. We had some.I am a hospitalist, an internist working in a hospital caring for patients. I have done this work for 25 years. I know the intensivist and the neurologist well. We have worked together, caring for many people over the years. My two surrogate partners were a nurse and a chaplain. The nurse had decades of professional experience, including in the intensive care unit. The chaplain was experienced in her work and comfortable with the challenges that arise in a hospital.The three of us had a robust discussion. I shared what most patients tell me when I ask about resuscitation status. “I don’t want to be kept alive on machines,” or “I don’t want to be a burden.” The ethicist gently reminded us that we were tasked with making a decision on behalf of this person, irrespective of what others would decide for themselves. It was challenging to tease out clues [End Page 10] that could guide us to what this man might choose for himself.Because of the location of his stroke, the patient was not expected to regain consciousness. He had been off sedation for more than a day and had not woken up. For the rest of his life, he would be institutionalized, ventilator dependent, and sustained with nutrition administered via a...