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2018 ; 6
(ä): 40
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Preserving fertility in an unconscious patient with Goodpasture
syndrome-medicolegal and ethical aspects
#MMPMID30062013
Stark D
; Stiller R
; Xie M
; Weber D
; Maggiorini M
; Hilty MP
J Intensive Care
2018[]; 6
(ä): 40
PMID30062013
show ga
BACKGROUND: Every day in the ICU, legal issues arise while treating sedated,
unconscious, and legally incapacitated patients. Whenever a life-saving treatment
cannot be discussed in a timely manner with an unconscious patient, doctors are
required by law to act according to the substituted judgment standard. However,
if it is not survival that is at stake, but conservation of reproduction and the
potential side effects are significant, the decision-making process becomes much
more difficult. Legal issues associated with possible harm to the patient on the
one hand and ethical issues with presumable benefit of the intervention on the
other hand give rise to difficult decisions. CASE PRESENTATION: We present the
case of a 24-year-old patient with Goodpasture syndrome. Because of rapid
aggravation of kidney function and alveolar hemorrhage-the latter requiring an
urgent initiation of mechanical ventilation-therapy with steroids,
plasmapheresis, and cyclophosphamide was immediately required. Knowledge of the
negative impact on fertility brought up the question about sperm
cryopreservation. According to the substituted judgment standard, together with
the mother of the patient and based on interdisciplinary evaluation of the
situation with specialists from the reproductive endocrinology and urology
department, the decision for a testicular sperm extraction in the absence of the
possibility to obtain the patient's informed consent was made. Immediate
chemotherapy was initiated and continued after the procedure. The patient
recovered from the acute illness and was informed retrospectively about the
testicular sperm extraction, which he received extremely positively. CONCLUSION:
Our aim is to highlight the legal objectives and ethical aspects of a
non-lifesaving but fertility-preserving intervention in an unconscious patient.
The need for decision-making in this kind of situation is rare and therefore
challenging. The present case may serve to encourage and guide other doctors in
similar situations.
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