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Invited Commentary
March 2014

Expanding Support for “Upstream” Surrogate Decision Making in the Hospital

Author Affiliations
  • 1Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Intern Med. 2014;174(3):377-379. doi:10.1001/jamainternmed.2013.13284

Mrs H, an 85-year-old woman with atrial fibrillation, congestive heart failure, and hemiplegia from a previous stroke, died in the intensive care unit (ICU) after a decision to withdraw mechanical ventilation. In recounting this decision, her daughter, MP, reported that it was the last in a series of difficult treatment choices that began months earlier. She participated in decisions to admit her mother to a nursing home because of recurrent falls, transfer her to the community hospital because of mental status changes, move her from the community hospital to a referral hospital when a stroke was diagnosed, and place a feeding tube when she failed a swallowing test. By the time she was admitted to the ICU with pneumonia, Mrs H had been through so much that “she was not my mother anymore,” MP said. Poignantly, MP explained that the decision to withdraw life-sustaining treatment was easier than the earlier decision—made on the hospital ward—to permit the feeding tube. She knew her mother would never have wanted the feeding tube but said that she had felt pressured by the neurologist’s recommendation to “give her a chance.”

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