Consent: central line with a family decision-maker

Scenario setup

Conversation partner: Emily, Daughter and designated healthcare proxy for the patient
Learner level: Clinical
Your role: Clinical medical student on the ICU team
Your scope: Conduct a supervised discussion of the proposed central line using the supplied clinical facts. The ICU clinician remains responsible for confirming consent and performing the procedure; bring unresolved questions or a refusal to them promptly.
Setting: At the ICU bedside
Situation: Emily’s mother is critically ill and cannot speak for herself. The team recommends more reliable IV access, and Emily is overwhelmed by the number of interventions.
Your task: Explain the recommendation and options, respond to Emily’s concerns, explore her mother’s values, and clarify an informed decision or what further discussion is needed. Agreement is not required for a successful encounter.
Time limit: 2 min
Who begins: You speak first. Your conversation partner waits for you.

Available information

Patient and capacity: Emily’s mother is 78, was admitted two days ago with pneumonia and developed septic shock. She is intubated and sedated and cannot participate in this conversation.
Conversation partner: Emily, in her 40s, is the patient’s daughter and designated healthcare proxy. She is at the ICU bedside.
Why additional access is proposed: Two peripheral IVs have failed. The ICU team is currently giving norepinephrine through a functioning, closely monitored upper-arm peripheral IV while arranging more reliable access. Other critical medications also need access.
Proposed procedure: The supervising ICU clinician proposes a temporary catheter in the right internal jugular vein in the neck, using ultrasound, sterile precautions and local numbing medicine. The catheter will be secured and covered; the team will check it and remove it when no longer needed.
Expected benefit: More dependable access can reduce interruptions in critical medication delivery when peripheral access is unreliable. The line supports treatment; it does not cure sepsis or guarantee recovery.
Material risks to discuss: Bleeding or vessel injury, infection, blood clots, and accidental lung injury causing a collapsed lung are material risks. Air entering the bloodstream or catheter misplacement can also occur. Ultrasound and sterile technique reduce some risks but do not eliminate them. No case-specific numerical probabilities are provided.
Alternatives and consequences: A suitable monitored peripheral IV can temporarily deliver vasopressors; central access should not delay their initiation. The team can reassess or replace peripheral access, but repeated failures may interrupt treatment. Delaying or declining this line requires a prompt discussion with the ICU clinician about ongoing access and treatment, not abandoning care.
Voluntary decision and supervision: Support an informed surrogate decision about this procedure. The supervising ICU clinician will address unresolved clinical questions and verify and document consent or refusal before proceeding. A student must not perform the procedure, promise an outcome, assume permission, or override the surrogate’s decision.
Basis for surrogate decisions: Ask what the mother has said or shown about treatment and what matters to her. Use known preferences to guide the discussion; if preferences are unavailable, discuss her likely interests with the supervising team.

What you’re assessed on

Explain the procedure: Explain the proposed line, where it goes, how placement and comfort are handled, and who will perform it, using everyday language.
Explain the recommendation: Connect the line to this patient’s unreliable access and ongoing treatment. Explain the expected benefit without promising recovery.
Discuss material risks: Explain bleeding or vessel injury, infection, clotting, and possible lung injury in understandable terms. Describe risk reduction honestly without claiming the procedure is risk-free.
Discuss options and choice: Explain monitored peripheral access and its limitations here, including the consequences of delaying or declining the line. Support a voluntary decision without pressure.
Check understanding and questions: Invite Emily’s questions and answer them understandably. Check what she understood about the recommendation and options, then confirm her understanding or clarify what remains confusing.
Respond to emotion and patient values: Acknowledge Emily’s distress, ask what matters to her mother, and relate the discussion to those values without assuming the family’s wishes.
Confirm the decision and next steps: Clarify whether Emily agrees, declines, or needs further discussion. Explain what you will document and bring to the supervising clinician. A thoughtful refusal can be a successful conversation.