Armed with the above knowledge, what practical recourse exists to hospitalists caring for patients in PVS whose hope for regaining consciousness is exceedingly remote? First, inquire about advance directives that may direct care in such circumstances. If advance directives are not present, identify the surrogate decision maker, keeping in mind the state-to-state legal variations in the surrogate hierarchy. If the appropriate surrogate wishes to continue care and the treating physician objects, attempt to achieve a consensus. Time to adjust to the devastating plight and repeated nonjudgmental discussions focusing on the patient’s wishes often lead surrogates to accept withdrawal, or at least to establish limits on care (e.g., do-not-resuscitate order, withholding antibiotics and nutrition). Involvement of hospital ethics committees, primary care physicians, social workers, and religious or cultural ombudsmen may facilitate this process. Barring a mutually acceptable solution or progress in this direction, physicians may decide to cede to the wishes of the surrogates or, as a last recourse, involve the judicial system to achieve resolution.
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