Can Family Consent to Remove a Ventilator for a Comatose Patient?

Q: Can Family Consent to Remove a Ventilator for a Comatose Patient?

Hello： If it is assessed that Grandma has spontaneous breathing but has throat swelling, there should be a chance to extubate after aggressive edema treatment. <br>Currently, end-stage diseases include cancer, HIV/AIDS, amyotrophic lateral sclerosis (ALS), and end-stage diseases

Is it possible to withdraw the ventilator?

Hello, Doctor.
My grandmother is about to turn 93 this year.
On March 9, she suffered from choking and asphyxiation.
The paramedics declared her without vital signs at the scene and subsequently transported her to the hospital for intubation and resuscitation.
According to the nurses, there were no vital signs for nearly 21 minutes, but she later regained a heartbeat and gradually began to breathe independently, although she remains in a comatose state.
Her eyes are tightly closed, and she only exhibits slight involuntary movement in her legs, but there are no reflex actions when suctioning secretions.
The doctor indicated that the likelihood of her becoming a vegetative state is extremely high.
(The family has signed a consent form to not pursue further invasive resuscitation, and if the ventilator is removed, it will not be reinserted.) The doctor stated that my grandmother's other organ functions are normal and that she can breathe independently, but her blood pressure and other vital signs are unstable (even before the incident, her blood pressure was very unstable), and she has throat swelling (which would prevent her from breathing if the ventilator is removed), thus she does not meet the criteria for ventilator withdrawal (she is currently receiving medication to reduce the swelling).
Additionally, the doctor believes my grandmother does not qualify as a "terminal patient," and therefore, palliative care is not being considered.
As a result, it seems that the day for her to be taken off the ventilator is far off.
I would like to ask if, under these circumstances, the family (all first-degree relatives of my grandmother) can consent to the removal of the ventilator? Is the doctor hesitant to remove it due to concerns about legal implications, or are there other reasons? If there are legal concerns, what kind of laws are involved? (The doctor is aware that the family does not wish to pursue aggressive treatment for my grandmother, but still hopes to increase her chances of survival before removal, which is contrary to the family's expectations.) We understand that my grandmother may still breathe independently for some time after the ventilator is removed, but we are fully aware of the pain associated with intubation and recognize that her prognosis is poor.
If she becomes a vegetative state, it would be quite distressing for both her and the family.
We hope to allow her to pass away peacefully.
I look forward to your response to my questions.
Thank you!

Beibei, 20~29 year old female. Ask Date: 2013/03/19

Dr. Huang Hongshuo reply Family Medicine

Hello: If it is assessed that Grandma has spontaneous breathing but has throat swelling, there should be a chance to extubate after aggressive edema treatment.
Currently, end-stage diseases include cancer, HIV/AIDS, amyotrophic lateral sclerosis (ALS), and end-stage diseases of the five major organs, which are the brain, heart, lungs, liver, and kidneys.
If Grandma has dementia, along with cognitive impairment and decreased self-care ability, as well as multiple complications, she may qualify as having an end-stage disease.
If it is assessed that Grandma has suffered from aspiration leading to hypoxic brain injury, with a poor prognosis, she may also qualify as having an end-stage disease, but this requires a joint diagnosis by two clinical physicians.
For other end-stage diseases, please refer to: http://www.wretch.cc/blog/narrativeKMU/7367726.
If there are further developments or other questions, please feel free to ask.

Reply Date: 2013/03/19

More Info

The situation you are describing regarding your grandmother's condition is indeed complex and emotionally challenging for the family. In the context of medical ethics and legal considerations, the question of whether family members can consent to remove a ventilator for a comatose patient involves several important factors.

Firstly, it is essential to understand that the decision to withdraw life-sustaining treatment, such as mechanical ventilation, typically requires careful consideration of the patient's medical condition, prognosis, and the patient's wishes (if known). In many jurisdictions, family members, especially immediate family, can be involved in the decision-making process, particularly when the patient is unable to communicate their wishes due to a comatose state.

In your grandmother's case, it appears that she has shown some signs of recovery, such as the ability to breathe independently, albeit with assistance from the ventilator. However, the medical team has indicated that her prognosis is poor and that she may be at risk of becoming a "vegetative state." This complicates the decision-making process, as the medical team must weigh the potential benefits and burdens of continuing or withdrawing treatment.

The physician's reluctance to remove the ventilator may stem from several factors, including:
1. Legal Concerns: Physicians often operate under strict legal frameworks that govern end-of-life decisions. They may be concerned about potential legal repercussions if they withdraw treatment and the patient subsequently dies. In many places, there are laws that protect healthcare providers when they act in accordance with the patient's wishes or advance directives, but these laws can vary significantly by location.

2. Medical Ethics: Physicians are guided by ethical principles, including the duty to do no harm. If the physician believes that there is still a chance for recovery or improvement in your grandmother's condition, they may feel ethically obligated to continue treatment, even if the family wishes to withdraw it.

3. Clinical Guidelines: Medical professionals often follow established clinical guidelines regarding the withdrawal of life support. These guidelines may include specific criteria that must be met before a ventilator can be removed, such as the patient's overall stability, the presence of certain reflexes, and the likelihood of recovery.

Given that your family has already signed a do-not-resuscitate (DNR) order and expressed a desire to avoid aggressive treatment, it is crucial to have an open and honest discussion with the medical team. You may want to ask the physician to clarify their reasoning for not proceeding with the withdrawal of the ventilator and to discuss the specific criteria they are using to assess your grandmother's condition.

If the family feels strongly about the decision to withdraw the ventilator, it may be beneficial to seek a second opinion from another physician or a palliative care specialist. These professionals can provide additional insights into the situation and may help facilitate discussions about end-of-life care options.

Ultimately, the decision to withdraw life support should be made collaboratively, considering the patient's best interests, the family's wishes, and the medical team's expertise. It is a deeply personal decision that requires compassion, understanding, and clear communication among all parties involved.

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