Substitute Decision Maker

Substitute Decision Maker

The Health Care Consent Act (HCCA) defines capacity as the ability to understand
information necessary to make an informed treatment decision and appreciate the
reasonably foreseeable consequences of a decision or lack of a decision (HCCA, 1996). As
mentioned previously, if a patient/client is determined to be incapable with respect to
their medical care, a SDM may give or withhold consent on the individual’s behalf. It is
important to note, however that the SDM is required to honour the patient/client’s
wishes, if known to be articulated when they were capable. If there are no known
capable wishes, then the SDM must act in the patient/client’s best interest.

A 35 year old patient who is suffering from end-stage MS is admitted to the ICU in severe respiratory distress. They are unable to communicate and their prior wishes are not known to the healthcare team. However, the spouse, acting in his capacity as SDM, is demanding that the patient be placed on life support. The RT is called to intubate. Is the SDM acting in the patient/client’s “best interest” and how should the RT proceeded?

The ethical principles involved are to do good and do no harm, balanced with the respect for free will.

For one thing, it is difficult to determine if the husband is acting in his wife’s best
interest, as we do not know if she had any prior competent wishes, or what they might have been. Her family physician is someone who may know, as hopefully this is a conversation they would have had, knowing the likely course of her disease. Another consideration is whether her current respiratory distress is the result of something that is curable (e.g., pneumonia) or a result of the disease progression. If at all possible, the RT should try to avoid intubation until such time as it can be established that this is the best interest of the patient/client.