569 Surrogate Decision Making: Who Has the Ultimate Say in Patient Care?

Abstract Introduction Burn patients may present with an inability to communicate. In these cases, we need to rely on surrogates such as the Medical Power of Attorney (MPoA) or next of kin. A MPoA gives the agent the authority to participate in medical decision and in accordance with their wishes. The agent may consent to, refuse, withdraw, or withhold treatment, including life-sustaining interventions. At times, they may feel unable to participate in decision making without assistance (i.e. family members). The process can become more complicated and decision making can become “muddied” due to others influencing decisions. In our state, the MPoA is the proxy if the patient is unable to participate in decision making; however, there are cases when the patient doesn’t have an MPoA and the next of kin is the surrogate. In these cases, the next of kin would be consulted in the following order: spouse, adult children, parents, and nearest relatives. Some next of kin may not know the patient’s wishes complicating their care. Methods Two cases involving surrogates: #1: 60-year-old man with a history of HIV involved in a MVC and sustained 30% TBSA third and fourth degree burns to the face, torso, and extremities. The severity of his injuries and outcomes were discussed with his wife. She was not certain what her would want and she consulted her family because she did not know what to do; however, she knew that he would not want to live like this. After talking to the family, the kids “over-ruled” her. They wanted aggressive care despite the risks of complications and inability to perform ADLs because of his severe facial and hand burns. Case#2: 40 something year-old man with a history of schizophrenia that sustained 65% TBSA third and fourth degree burns to his face, neck, torso, and extremities due to self-immolation. The patient’s mother was identified, and it was explained to the patient’s mother that if he did survive his injury, he will not be able to perform any of his ADLs due his hand and facial burns. The patient’s mother wanted everything done for her son. Results Both patients were unable to perform ADLs due to their injuries. One patient was discharged for further inpatient care and the other was discharged home because his mother refused further care. The first patient was unable to communicate about his thoughts on his outcome. The other patient was discharged home. He was upset about what he looked like. He also told the staff that he will do his best to finish what he started. Conclusions Complex issues can arise when the patient cannot communicate their wishes and the next of kin plays the role of surrogate. The family may disagree and alter the decision-making process. After seeing this scenario play out and patients not being happy about their outcomes, the policies regarding surrogate decision making should be re-evaluated.