Bioethics - Case Study #1
Case Study #1
This is a theoretical case taken from VHA Intensive Ethics Advisory Committee Training, 1998, as presented by Arthur R. Derse MD, JD
An 87-year-old woman widowed for six years, who is otherwise healthy, was visiting another city and abruptly became ill She was seen in the emergency department of the local VA and admitted to the on-call physician. The on-call physician (who has not previously seen her) made the diagnosis of bowel obstruction arid made arrangements for a surgeon to evaluate her. The surgeon recommended surgery and obtained her consent for surgery. The surgeon expects an uneventful recovery. She is told that she will be on a ventilator for a short time after surgery. The patient tells the surgeon that is OK as long as it is for a short time. She tells the surgeon that she doesn’t want to be dependent upon machines. She was asked upon admission whether she had an advance directive. She replied that she has a living will and a power of attorney for health care which names her daughter (who does not live in the area) as her health care agent.
The patient undergoes surgery, which is successful in treating the underlying problem and does not show any malignant causes, but in the recovery room she has a cardiopulmonary arrest and is resuscitated. She is transferred to the ICU in the care of the on-call physician The physician attempts to wean her gradually from the ventilator, but this is unsuccessful. Three days later, she has regained consciousness but is still intubated. Though she cannot speak because of the
ventilator, she is able to write and asks that the tube be removed. The attending physician tells her that she is dependent upon the ventilator and the patient needs to remain on the ventilator until she can breathe on her own. She writes that she understands that she may die, but she does not want to be on machines. Her only children -- a daughter and son -- - have arrived. She repeats her wish to them that she wants the tube removed. She writes to her daughter that “I don’t want to die, but we all have to die sometime, and I don’t want to have to live on a machine. I know that whatever the outcome, God will take care of me.” Her daughter tells the physician that her mother is adamant that she be off of machines and she respects her mother’s wishes, even if she cannot breathe on her own. She says this is consistent with her previously expressed wishes and her religious beliefs. Her son tells the physician that he disagrees with his sister -- since his mother doesn’t have a terminal condition, he can’t see why she shouldn’t be forced to put up with the ventilator until she can be weaned from it. He feels that she is being shortsighted, and she will be thankful to have been kept on the ventilator when she is finally able to be weaned.
Questions
1. Does the patient have the right to refuse continued use of the ventilator?
2. Does the fact that the patient’s condition is not terminal affect your opinion?
3. Did the patient consent to the use of the ventilator by consenting to the surgery and its possible complications?
4. Does the patient have decision-making capacity?
5. Should the patient’s religious beliefs be taken into account? If so, how?
6. What if the physician does not want to remove the patient from the ventilator?
7. If the patient were found to be non-decisional, who should make decisions for the patient?
8. How should the attending physician deal with the difference of opinion by family members?
9. The attending physician asks the Ethics Advisory Committee for a consult as to whether he should accede to the patient’s request. Will they make the decision?
Answers
The PCMS Bioethics Committee had several consensus answers.
1. Does the patient have the right to refuse continued use of the ventilator? Yes, and we feel she has the capacity to make such a decision.
2. Does the fact that the patient’s condition is not terminal affect your opinion? It should not. The patient still has capacity to make decisions about her care.
3. Did the patient consent to the use of the ventilator by consenting to the surgery and its possible complications? Yes, but she also qualified that consent by saying it was OK as long as it was for a short time. A physician, however, can and should explain his/her experience with ventilators and offer his/her judgment about use of it in this case.
4. Does the patient have decision-making capacity? We feel she does, at least to make this decision. To determine capacity there must be a dialogue. Here, that dialogue takes place in writing questions and answers. By examining the patient’s answers it seems she understands the situation, the problem and the consequences. It also seems consistent with her previously expressed wishes.
5. Should the patient’s religious beliefs be taken into account? If so, how? Yes, if she has capacity. Her beliefs are wrapped up in her personality and her decision. Sometimes church leaders can be brought in to discuss the decision to ensure religious beliefs are met.
6. What if the physician does not want to remove the ventilator? The patient can fire the physician or the physician can find a physician who will agree with the patient’s wishes.
7. If the patient were found to be non-decisional, who should make decisions for the patient? In this case, the answer is clearly the daughter. There is a living will and a power of attorney. Or is there? We are told one is in existence, but no one seems to have seen it.
Under Arizona law, physicians must make a reasonable effort to locate and follow a health care directive. If there is no living will, the patient is non-decisional, and no medical power of attorney has been located and no court-appointed guardian is present, then in Arizona there is a statute that allows for surrogate decision makers. They are presented in order of priority.
Spouse (unless legally separated)
An adult child (if more than one seek consent of majority reasonably available)
A parent
Domestic partner (if no one has assumed financial responsibility for the patient)
Brother or sister
Close friend (who has exhibited special care and concern and is familiar with the patient’s health care views and is able to become involved with the patient’s care and act in the patient’s best interests)
If none of the above can be located, the physician can make decisions after consulting the institution’s ethics committee. If this is not possible, decisions can be made after consultation with another physician who concurs in the decision.
8. How should the attending physician deal with the difference of opinion by family members? Although it is difficult to arrange, the key is to have the whole care team meet with the son and daughter and to try to have a meeting of the minds. Often the son and daughter have heard different things at different times from members of the care team. The key question for the relatives is, “What do you understand about this case?”
9. The attending physician asks the Ethics Advisory Committee for a consult as to whether he should accede to the patient’s request. Will they make the decision? No. ethics committees in contemporary hospitals and community settings do not, as a matter of policy, make final decisions. There are no ethics police who will swoop down with perfect solutions and enforcement mechanisms. Life at times is messy, especially so in the highly charged and incredibly diverse culture of modern urban health care. What ethics committees do best is bring together all stakeholders and that diversity of opinion (cultural norms, morality, legality, efficacy and compassion) into the form of a consulting team. The team gathers information from medical records and stakeholders (including the family and patient). The team then provides alternatives to the patient or legal surrogate(s) and reflective space to evaluate those alternatives. The team also provides a mechanism by which the assembled stakeholders are assisted in communicating their needs and desires. Anger, suspicion, ego, ignorance and other factors can often be dispelled. The team can suggest scenarios that none of the principles, deep in anxiety or fear, have not considered or imagined. In short, the participants are given the option of being human, not perfect beings. It is in this way that difficult and wrenching decisions can be made that at least address many if not most of the needs of the patient, family, institution and society.
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