• Alexandra Lloyd-Smith Sequeira and Ariane Lewis.
• Department of Neurology, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA.
• Neurocrit Care. 2017 Oct 1; 27 (2): 173-179.

BackgroundPatients without surrogates are referred to as "unbefriended." Because these patients do not have representatives to assist with medical decision-making, patient autonomy and self-determination, fundamental concepts of American healthcare, are jeopardized.MethodsWe present a case of an unbefriended patient in a vegetative state and discuss the ethical and legal complications associated with management of unbefriended patients.ResultsAn unbefriended patient was admitted to our hospital with a cardiac arrest in the setting of an intracerebral hemorrhage. Despite aggressive medical and surgical management, he suffered significant brain injury and was in a vegetative state. In our state, unless an unbefriended patient will imminently die despite medical therapy, all measures must be taken to prolong the patient's life, so a tracheostomy and feeding tube were placed and he was transferred to a long-term care facility. The process for making decisions on behalf of unbefriended patients is complicated and varies throughout the country. Some potential ways to avoid these complex situations include: early conversations about treatment wishes while patients have capacity, mandatory advance directives, and increased training and reimbursement for physicians to proactively have end-of-life discussions.ConclusionThe unbefriended are one of the most high-risk patient groups. Because our patient had no surrogate with whom we could have a goals-of-care discussion, we were obligated to continue aggressive management despite knowing it would prolong, but not improve, his life. Proactive preventative measures to identify and document end-of-life wishes may make management of these patients less ethically and legally complicated.

17 keywords...

hide…