Graduating from Life: Exploring the Religious and Legal Complexities in an End-of-Life Care Case of a 4th-Year Medical Student
Ummesalmah Abdulbaseer, MD,Ramandeep Kaur, MD, Alejandro Pinedo, MD, Misha Shah, DO, Manuel Antonio Hache Marliere, MD, and Jessica Kuppy, MD, Rush University Medical Center, Chicago, IL
Background: A 32-year-old male in his last year of medical school with a history of substance use disorder, septal perforation, and depression presented to a Midwestern academic medical center after cardiac arrest likely in the setting of drug overdose. His urine tested positive for benzodiazepines, cocaine, and opiates. He was subsequently intubated and sedated and sent to the ICU. His prognosis was grim, as further workup revealed signs of anoxic brain injury. Unfortunately, his family, who were all physicians, were unable to accept this, with the mother once unplugging the ventilator to assess the patient’s breathing abilities. Their Orthodox Jewish faith prevented them from removing his life support and supporting his organ donor status. Multiple conversations were had regarding the patient’s goals of care, revealing a tumultuous relationship between his parents, his surrogate decision makers. Ultimately decisions could not be reached, but the tide turned when it was revealed by chance that the patient was adopted by an aunt, and never re-adopted by his own parents, thus making her the surrogate decision maker. She did not share similar religious beliefs and ultimately she approved withdrawal of care, and he was able to be evaluated for organ donation.
Discussion: End-of-life care discussions are complex, often confounded by family dynamics. However, this case dealt with issues of religion, legality, and ethics that enhanced such complexity and shaped the interactions between the medical team and the family. Their Orthodox Jewish faith played a significant role in how they saw death, which emphasizes the sanctity of life and the importance of preserving it. For some, brain death is not accepted as death at all. The father felt life supporting medications should not be stopped and ultimately patient should get a tracheostomy and feeding tube placed, as that was more in line with their religious views. The family was distressed hearing of his organ donor status and ultimately vehemently opposed as they felt it contradicted with their religious values, as some rabbis forbid organ donation of vital organs. However, the act of consenting to be a donor is a first person authorized advanced directive, thus is legally binding and cannot be overridden by family, even after death. Young adults typically do not designate a healthcare power of attorney, with only up to 36% of total US adults completing it. However, when not present, and patients are incapacitated, it can create a new variable in decision making. Ultimately the parents would become his surrogate decision makers, but they were unable to come to an agreement – with the mother coming to terms with the situation and his father, who had been absent from his life, struggling. Ultimately however, this was disregarded it was found they were superseded in legal decision making – which could have been done earlier if the family has disclosed it earlier. Thus, this suggests that if no formal POA paperwork is present, thorough investigation should be done. Overall, this case, a true matter of life and death, ended honorably. The medical team was able to properly navigate religion and law to ensure the patient passed in a way where his wishes were honored above all, given his organs were donated in the end.
Conclusion: End of life care conversations are complex and need to be allocated significant time to ensure death of patients are done in an honorable manner, emphasizing their wishes, as well as those of their family, such as in regard to religion, organ donation, and legal decision making.
Discussion: End-of-life care discussions are complex, often confounded by family dynamics. However, this case dealt with issues of religion, legality, and ethics that enhanced such complexity and shaped the interactions between the medical team and the family. Their Orthodox Jewish faith played a significant role in how they saw death, which emphasizes the sanctity of life and the importance of preserving it. For some, brain death is not accepted as death at all. The father felt life supporting medications should not be stopped and ultimately patient should get a tracheostomy and feeding tube placed, as that was more in line with their religious views. The family was distressed hearing of his organ donor status and ultimately vehemently opposed as they felt it contradicted with their religious values, as some rabbis forbid organ donation of vital organs. However, the act of consenting to be a donor is a first person authorized advanced directive, thus is legally binding and cannot be overridden by family, even after death. Young adults typically do not designate a healthcare power of attorney, with only up to 36% of total US adults completing it. However, when not present, and patients are incapacitated, it can create a new variable in decision making. Ultimately the parents would become his surrogate decision makers, but they were unable to come to an agreement – with the mother coming to terms with the situation and his father, who had been absent from his life, struggling. Ultimately however, this was disregarded it was found they were superseded in legal decision making – which could have been done earlier if the family has disclosed it earlier. Thus, this suggests that if no formal POA paperwork is present, thorough investigation should be done. Overall, this case, a true matter of life and death, ended honorably. The medical team was able to properly navigate religion and law to ensure the patient passed in a way where his wishes were honored above all, given his organs were donated in the end.
Conclusion: End of life care conversations are complex and need to be allocated significant time to ensure death of patients are done in an honorable manner, emphasizing their wishes, as well as those of their family, such as in regard to religion, organ donation, and legal decision making.