f. When No Next of Kin or Guardian. When there is no next of kin or guardian
and the physician feels that a DNR order is appropriate, the matter may be referred to
the Deputy Commander of Clinical Services (DCSS) and the ethics committee for
decision and approval. The ethics committee, by regulation, should consist of at least
two physicians, a nurse, a chaplain, and a Judge Advocate officer. (The panel can also
resolve conflicts between the physician and family members regarding the
appropriateness of a DNR order. If there is still no agreement between the surrogate
decision maker and the staff after the ethics committee has reviewed the case, it will
then go to court.)
IS SUBSTITUTED JUDGMENT A LEGAL FICTION?
Dr. Christine Castle, Medical Ethicist and Chief of Internal Medicine at the
University of Chicago Medical Center, believes that living wills are not the real
solution to the problem of preserving the autonomy of incompetent patients. The
appointed decision makers must decide what the patient would have wanted in a
given situation. Most of the judgments that the guardian or next of kin must make
involve complex emotional relationships. It is, she contends, hard to sort out one's
own feelings from what the patient would have wanted. She believes that the
courts are realizing that substituted judgment is, in fact, a legal fiction, that we
cannot really place ourselves in the shoes of another.12 But admittedly, at the
present time we do not have a better alternative.
WITHDRAWAL OF LIFE SUPPORT
a. Criteria for Withdrawal of Life Support. Patients with a terminal condition
or those in a persistent vegetative state (irreversible coma) are candidates for
withdrawal of life support.
b. Treatment That Artificially Prolongs Life. Life-sustaining treatment that
serves only to artificially prolongs life such as: intravenous therapies (artificial nutrition
and hydration), lavage feedings (nasogastric tube), kidney dialysis, CPR, and artificial
respiration may be withdrawn in the event of a terminal condition.
life-sustaining treatment: any medical procedure or intervention which serves
only to artificially prolong the dying of a patient, diagnosed and certified by at
least two physicians as afflicted with a terminal condition or as being in a
It should be noted that medical interventions necessary to alleviate pain are not
considered life sustaining.