Caitlin B. McGeehan is Palliative Care Nurse/Lead Clinical Nurse, Department of Medicine, Section of Palliative Medicine, The Johns Hopkins Hospital, 600 N Wolfe St, Blalock 342B, Baltimore, MD 21287 (
Lauren Berninger is Assistant Professor, Department of Medicine, Division of General Internal Medicine, Section of Palliative Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
AACN Adv Crit Care. 2024 Sep 15;35(3):228-237. doi: 10.4037/aacnacc2024399.
The experience of serious illness or injury frequently results in increased vulnerability. In cases in which decision-making capacity is compromised, this vulnerability is compounded by threats to a patient's autonomy. This case report presents an opportunity to explore the elaborately entwined relationship between autonomy and vulnerability in patients with severe impairment who are reliant on surrogate decision-makers. Expanded views of autonomy and vulnerability are applied to the case of a young woman with a severe and life-altering spinal cord injury and iatrogenic loss of decisional capacity to illustrate how one can experience enhanced autonomy despite special vulnerability and can be made less vulnerable through surrogate-mediated autonomy. Also revealed is how attitudes and actions of surrogates can potentiate pathogenic vulnerability and disturb the balance between patient autonomy and vulnerability. Through methodical review and robust deliberation, clinical ethics committees can play a stabilizing role in helping distressed care teams reconcile the two.
患病或受伤的经历通常会使人变得更加脆弱。在决策能力受损的情况下，患者的自主权受到威胁，这使他们的脆弱性更加严重。本病例报告提供了一个机会，可以探讨严重受损且依赖代理人决策的患者中自主权和脆弱性之间复杂交织的关系。本病例报告通过一个年轻女性严重且改变生活的脊髓损伤和医源性丧失决策能力的案例，扩展了对自主权和脆弱性的理解，说明了一个人如何能够在特殊脆弱性的情况下增强自主权，以及如何通过代理人介导的自主权使自己减少脆弱性。还揭示了代理人的态度和行为如何增强潜在的脆弱性，并扰乱患者自主权和脆弱性之间的平衡。通过系统的审查和强有力的审议，临床伦理委员会可以在帮助困扰的护理团队协调两者方面发挥稳定作用。
