A. Getting a court appointed guardian is acceptable and may be supported by the Code in this case, but it is too early to tell. Given that his life is now threatened, Mr. Douglas would most likely agree to the surgery if he were conscious. Opinion 8.081, "Surrogate Decision-Making" states that "When a physician believes that a decision is clearly not what the patient would have decided or could not be reasonably judged to be within the patient's best interests, the dispute should be referred to an ethics committee before resorting to the courts." Because of the urgency of this situation, however, it may be difficult to call an ethics consultation in time, so the physicians might move for an emergency court appointment of another guardian for Mr. Douglas.
B. Continuing to recommend bypass surgery to Mrs. Douglas is preferable; it is supported by the Code in Opinion 8.081, "Surrogate Decision-Making": "Physicians should provide [the surrogate with] advice, guidance and support; explain that decisions should be based on substituted judgment when possible and otherwise on the best interests principle; and offer relevant medical information as well as medical opinions in a timely manner." Mrs. Douglas does not appear to know why Mr. Douglas did not want the by-pass surgery and the only reason he gave Dr. Kim was the business deal. Accordingly, both substituted judgment and best interest standards would likely call for the surgery, but further conversation with Mrs. Douglas may confirm or refute this.
C. Prepping Mr. Douglas for by-pass surgery should be avoided because it violates the Code in Opinion 8.081, "Surrogate Decision-Making": "Physicians should recognize the proxy or surrogate as an extension of the patient, entitled to the same respect as the competent patient." Without further discussion between Mrs. Douglas and Drs Kim, Carlson, and Iminez, prepping Mr. Douglas for surgery would deny her the respect due a legitimate surrogate decision maker.
D. Treating Mr. Douglas without surgery (i.e., catheterization and/or pharmacological treatment) should be avoided because it is not supported by the Code and may violate the physician's responsibility to ensure decisions are made "on the basis of sound substituted judgment reasoning or the best interest standard" (from Opinion 8.081, "Surrogate Decision-Making").