Mr. Winn

Mr. Winn is a 50-year-old construction worker, who has been separated from his wife (though still legally married) and with a teenage child. He had a history of laryngeal carcinoma diagnosed one year before. He had a total laryngectomy and received radiation therapy, but the disease recurred. His admission was initially prompted by increased shortness of breath and facial swelling following chemotherapy. He spent 2 weeks in the medical intensive care unit (MICU) for stabilization and treatment of pneumonia. Mr. Winn’s primary care physician has encouraged him to consider a "Do-Not-Resuscitate" order, but Mr. Winn’s oncologist feels it is too soon to issue such an order.

Mr. Winn is in increased pain and he has facial swelling, periodic seizures, and has developed a second pneumonia and progressive weakness. At all times, he is bed bound and artificially fed. His pain was relatively well controlled but the facial swelling was uncontrollable. Initially, communication was possible to some extent through hand signals, but Mr. Winn has subsequently lost his ability to communicate. Mr. Winn seems to be deteriorating and his wife and primary care physician want to be put him into palliative sedation and have his feeding tube withdrawn. Mr. Winn’s oncologist, however, stridently objects citing a 5% chance Mr. Winn could still recover.  The oncologist cites the fact that Mr. Winn had not chosen a DNR when the primary care physician offered it, as evidence he wanted to continue aggressive care, but Mr. Winn’s wife is not sure this is what he would have wanted. When pressed, she admits they never discussed such issues and is not really sure what he would want.

Dr. Wade

Dr. Wade is an anesthesiologist who has just been assigned to an off-campus location on the day of his current procedure, which is a transvaginal oocyte retrieval. During a conversation with the patient in the preanesthesia area, he learns that she is having pre-implantation genetic diagnostic studies of any fertilized eggs, and that these results will determine future options, which include deciding to reject and discard any that would test positive for rare inheritable diseases such as cystic fibrosis or Down syndrome. Dr. Wade is astounded. He has previously stated to his supervisors and other members of the health care team that he has a conscientious objection to participating in certain reproductive procedures. However, at this moment, time is of the essence as the infertility obstetrician indicates that the time of the retrieval must take place within the next hour. Dr. Wade is conflicted and unsure what to do.

Mrs. Finn

Mrs. Finn is an 80-year-old woman, with non-resectable lung cancer, diabetes, hypertension, chronic renal insufficiency, and severe degenerative joint disease. She was stable, walking short distances with a walker, fully cognizant, and living in a retirement center until 2 days prior to admission when she became markedly short of breath. She was diagnosed with lobar pneumonia. Mrs. Finn has three children and eight grandchildren. She had not written a living will and is very religious, wishing to leave her fate to a higher being.
Despite initial improvement with treatment, Mrs. Finn. developed high fevers and septicemia on her third day of hospitalization. Stronger antibiotics, vasopressors, and fluids did not prevent worsening hypoxemia. She developed acute renal failure and lost full mental capacity despite aggressive treatment. Her family has asked that “everything be done.” Physicians realize Mrs. Finn. needed dialysis and intubation to prevent imminent death. Given her incurable lung cancer, it was unlikely that Mrs. Finn would ever be extubated. Under the best circumstances, she would not return to semi-independent living and would face continued pain and further decline from her cancer. The family still requested full treatment, saying they are hoping for a miracle, but will settle for as much time as they can get with their mother while she is still alive. The residents are frustrated and divided on the issue of whether Mrs. Finns care is futile.

Mr. Roberts

Mr. Roberts was admitted to the University Medical Center with heart failure. He was well known to the staff, having had quadruple bypass surgery 10 years prior when he was 55. He had been a frequent visitor to the cardiology and surgery service with various heart complications since then. After a long night of tests and consultations, the cardiology team diagnosed Mr. Roberts with end-stage heart failure. Due to his past medical history, he was deemed to be ineligible for a heart transplant. Visibly distressed by the news, Mr. Roberts, his hands tightly clasping his wife's, asked the attending physician about his prognosis. In his current condition, he was told, he probably had a month to live. "Come on doc, there must be something you can do." The attending physician told Mr. Roberts he would consult with his colleague, Dr. Jones, to see whether there were any treatment alternatives.

Dr. Jones, an eminent cardiac surgeon at the medical center, had been preoccupied with transplants and machines since his medical school days. Although he had performed numerous heart surgeries in his 25 years of practice, the goal of creating a cardiac device that would eliminate the problems of rejection or failure had long been in his dreams. For the past 20 years, he had been developing an artificial heart in collaboration with its manufacturer, Hipprotech. In the past year the FDA approved the device for a clinical trial with humans, and 10 months ago they implanted one in a patient to much fanfare.

Although the implant occurred without incident, the patient sustained several embolic strokes and died after two months. The autopsy had shown a thrombus within the artificial heart, a problem thought to have been resolved in developing the device. After deliberating, Dr. Jones's group had decided to press ahead with the trial and to collect more data from the next eligible patient to determine whether the clotting problem was device-based or due to the patient, as well as to gather more data about the implant.

They could not decide, however, whether to disclose the clotting problem to the next patient. It was not part of the informed consent protocol, but some of Dr. Jones's colleagues argued that the problem might be in the device. They adjourned the meeting without a consensus. At that point, the cardiology service paged Dr. Jones with the news of a new candidate for the trial. Driving in to the hospital, he was excited about continuing his research. On arrival, he found that the patient's file was already on his desk. Eager to familiarize himself with the profile before talking to the patient and family about joining the trial, he immediately flipped open the folder. To his surprise, the patient was one that he had operated on several times in the past decade: Mr. Roberts.

Georgina

Georgina is a 16-year-old admitted to the ER with pre-term labor.  Ultrasound reveals that she is 32 weeks pregnant, and upon clinical exam it is determined she is 4 cm dilated.  The emergency physician immediately institutes tocolytic drugs to stop the contractions and stem off labor for a time and also administers corticosteroids to strengthen the baby’s lungs in the event that the baby is delivered early.  The OBGYN on call is consulted and requests that the woman be brought to the labor & delivery unit.  After reviewing the patient’s ultrasound, the OBGYN notes that the baby is in a breech position, which means that a cesarean section will most likely be required.  Despite tocolysis, the girl’s labor continues to progress and fetal monitoring shows that the baby is experiencing significant fetal distress.  The OBGYN informs Georgina that an emergency c-section will have to be done to save the baby.  Georgina, however, states that she “does not want to be cut into” and refuses to give her consent for the procedure.  The OBGYN explains that time is of the essence if the baby is to have the best outcome but Georgina is adamant no c-section be performed.  The OBGYN insists that it must be done and the Georgina’s grandmother, who has been with her since entering the ER, intervenes and says “my granddaughter has made her wishes known.”  Furious, the OBGYN states that “the baby will likely die or be severely impaired if a c-section is not done stat.”  Georgina’s grandmother does not give in, however, and says if anything is done against her granddaughter’s wishes, she will bring suit against the OBGYN and the hospital. 

Mrs. M

Mrs. M is an 83-year-old woman with COPD and a history of one previous stroke. She has chronic medical problems including degenerative joint disease, osteoporosis, and coronary artery disease. With extensive support from her family and a home health service, she has been able to remain at home in spite of her worsening conditions. Over time her skilled nursing needs increased, and now, care at home has become very difficult and increasingly impractical. For the past year, Mrs. M has adamantly refused to move to a nursing home, though her family believes admission is the best option for her. She does not want any more aggressive care. She saw one of her friends live for months on a vent, and she is afraid that she will get stuck in a similar place.

In the last month, it has become clear, even to Mrs. M, that the family and home health service can no longer meet her needs at home and she needs to move to a nursing facility. Reluctantly, she has agreed to consider a nursing facility if her children and social worker can find a place she agrees is suitable.

Last week, Mrs. M mentioned to you, her home health nurse, that she recently read a newspaper account of a woman who chose to stop eating and drinking so she could die on her own terms. This week, Mrs. M updates you that her children have found a facility they think is “nice”. After she tells you about this development, she confides in you that she wishes she could end her own life and that she does not want to move to a facility. Towards this end, she is planning to refuse food and water and to stop taking all medicines other than pain relievers. Her goal is to achieve a quicker end to life and wants to avoid unwanted aggressive care. You are concerned about this choice and are unsure how to respond or what to do.

Andrea Gonzalez

Andrea Gonzalez is an 18-year-old single mother who works on a mushroom farm. Ms. Gonzalez was referred to a tertiary medical center for prenatal care when her fetus was found by her community health center to have low amniotic fluid, a sign of a birth defect. An ultrasound showed the unborn baby had extremely small kidneys and there was a significant chance that, after delivery, her kidney function would be insufficient for survival.

            The baby, Lynn, was spontaneously born at 38 weeks. Though full term, her bladder is completely absent and she has kidney failure. Despite these problems, she is able to produce some urine. She also has normal urethral, vaginal, and rectal orifices. She has no abnormalities of the nervous system to suggest that she will have problems walking and talking, or to suggest that she will be mentally challenged. She is able to breathe completely on her own and there is no evidence of any problems with the heart, lungs, or digestive system that would affect quality of life. The situation does not require an immediate decision, but clearly, medical intervention will be necessary if she is to be given some chance of a reasonably extended life. She was admitted to the Infant Intensive Care Unit for evaluation and management of her condition.

            The attending physician, Dr. Watson, is a neonatologist who is in charge of baby Lynns’ care. Dr. Watson does not think it possible to construct a bladder for her at this time. Dr. Watson called for a nephrology consult. The nephrologist, Dr. Hyde, sees only two possible options. Baby Lynn could be started on peritoneal dialysis with the intention of listing her for kidney transplant when her weight reaches 10 kg, or the team could recommend supportive care to help the mother keep her baby comfortable until she peacefully dies of kidney failure. In examining these options, Dr. Hyde believes that it is not possible for the mother to perform outpatient peritoneal dialysis and recommends supportive care only.

            Dr. Watson, however, thinks it is mandatory to start dialysis and plan a transplant for baby Lynn, whose disabilities are confined to her urinary system. She strongly believes that baby Lynn could develop to live a reasonably normal life in which she could become educated, employed, and married, if her kidney problem can be managed.

            Ms. Gonzalez loves her baby and does not want Lynn to die, but she has a very low income and no family support. She is incapable of providing the necessary outpatient care for her baby without substantial assistance. She is the only decision-maker for Lynn’s care.