Case Presentation: The patient is a 74 year old woman with past history of dementia and an aggressive right upper lobe cavitary mass who presented with post-obstructive pneumonia. The lung mass was diagnosed two years prior, however, the patient refused further workup. The patient named her two daughters to be dual healthcare powers of attorney (HCPOA). The patient was intubated on hospital day (HD) 2, extubated on HD 17, and re-intubation on HD 22. Ethics was consulted on hospital day 23 as the HCPOAs refused tracheostomy, PEG, and LTAC, while simultaneously refusing to change the code status or pursue comfort care. Though they acknowledged multiple times that their mother would not want to continue aggressive care, they did. The ethics committee determined that the failure to make a decision was, in fact, making a decision to impose undue suffering. Legal processes were initiated to appoint a new HCPOA. The patient was not able to communicate through voice or written word. On HD 33, the psychologist assessed the patient through the use of gestures, such as nodding to imply yes, shaking of the head to imply no, and shrugging to convey she did not understand. The psychologist asked the patient multiple questions in multiple ways to confirm capacity. The patient expressed understanding and desire for comfort measures only and compassionate extubation. This process was repeated two days later with the same result. On HD 38, the patient was extubated and passed.
Discussion: It is widely accepted that if patients can speak for themselves and have awareness of the situation, they have capacity to make their own decisions. In lieu of speaking, a patient, if deemed to have capacity, may also write their wishes on paper for physicians to follow. This case emphasizes an important and common situation when a patient is neither able to speak nor write? There is literature and legal precedent to support decision making through the use of spoken or written word. However, we could not find any cases where basic movements of the head were used in making these life-altering, critical decisions. These decisions, however, were consistent with years of documented encounters explicitly stating the patient did not want to be intubated.
Conclusions: It is difficult to ascertain whether the decision-making process of determining capacity was because of horizontal and vertical movements of the head, or because these decisions were in line with previous documented wishes. The timeline of this patient’s hospital stay was markedly extended in hopes of providing insight to the dual HCPOAs of their mother’s condition. It calls to question how quickly we, as physicians, should act if a HCPOA is going against a patient’s known wishes? Are nodding, shaking, and shrugging grounds to verify a patient’s wishes to effectively forgo aggressive medical management?