Cardiac Interventions in the Absence of Assent: An Ethical Dilemma

A 63-year-old woman with schizophrenia presented with prosthetic mitral valve endocarditis complicated by complete heart block and declined surgical intervention. The patient was deemed to not have decisional capacity after a formal evaluation by the psychiatry service, and a surrogate decision-maker used the ethical principles of substituted judgment and best interest standards for surgical consent on behalf of the patient. The patient provided passive assent (did not resist transport to the operating room). The patient underwent successful redo mitral and aortic valve replacements and recovered well postoperatively. In conclusion, it is important for cardiovascular clinicians to be familiar with the ethical elements of surrogate decision-making, including patient autonomy and its limits, determination of decision-making capacity, and the standard of surrogate decision-making.