Neurocritical Care

, Volume 27, Issue 2, pp 173–179 | Cite as

Ethical and Legal Considerations in the Management of an Unbefriended Patient in a Vegetative State

  • Alexandra Lloyd-Smith Sequeira
  • Ariane LewisEmail author
Ethical Matters



Patients without surrogates are referred to as “unbefriended.” Because these patients do not have representatives to assist with medical decision-making, patient autonomy and self-determination, fundamental concepts of American healthcare, are jeopardized.


We present a case of an unbefriended patient in a vegetative state and discuss the ethical and legal complications associated with management of unbefriended patients.


An unbefriended patient was admitted to our hospital with a cardiac arrest in the setting of an intracerebral hemorrhage. Despite aggressive medical and surgical management, he suffered significant brain injury and was in a vegetative state. In our state, unless an unbefriended patient will imminently die despite medical therapy, all measures must be taken to prolong the patient’s life, so a tracheostomy and feeding tube were placed and he was transferred to a long-term care facility. The process for making decisions on behalf of unbefriended patients is complicated and varies throughout the country. Some potential ways to avoid these complex situations include: early conversations about treatment wishes while patients have capacity, mandatory advance directives, and increased training and reimbursement for physicians to proactively have end-of-life discussions.


The unbefriended are one of the most high-risk patient groups. Because our patient had no surrogate with whom we could have a goals-of-care discussion, we were obligated to continue aggressive management despite knowing it would prolong, but not improve, his life. Proactive preventative measures to identify and document end-of-life wishes may make management of these patients less ethically and legally complicated.


Unbefriended End-of-life Ethics Medicolegal Vegetative state Goals-of-care 



The authors did not receive any funding for this manuscript.

Authors Contribution

Alexandra Lloyd-Smith Sequeira was responsible for conception and design, drafting the manuscript, and final approval of the manuscript. Ariane Lewis was responsible for conception and design, supervision, critical revision of the manuscript, and final approval of the manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper.


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Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of NeurologyNYU Langone Medical CenterNew YorkUSA
  2. 2.Department of NeurosurgeryNYU Langone Medical CenterNew YorkUSA

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