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and his wife and primary care physician want to be put him into palliative sedation and have his feeding tube withdrawn.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.

Chloe Erikson

Chloe Erikson is a 22-year-old woman who has been struggling with anorexia since the age of 16. After losing both of her parents in a car accident at that age, Chloe began to suffer from depression and an eating disorder. Although she has been receiving psychological treatment for almost six years, she has not been able to lead a normal life. Despite the fact that eating disorder treatment programs isolated Chole from every day life, they did not succeed in treating her mental illness; each time she is released from treatment, her weight drops precipitously and she must be re-committed within a few months. Chloe hates being in treatment, but she can’t control her disease sufficiently to stay healthy and independent. When she is not in an in-patient eating disorder treatment facility, she lives with her sister Heather Moriarty and Heather’s husband, John, who love Chloe and are fortunately able to support her financially.

            Following release from her last in-patient stay, Chloe decided she wanted to obtain an advance directive and healthcare proxy stating that the next time her weight dropped to a dangerous level, she did not want to be sent to a hospital ICU by ambulance if she collapsed. Although when her weight reaches a life-threatening low, Chloe is vulnerable to collapse and fatal heart attack caused by electrolyte imbalance, she has decided that dying as a result of such an episode would be preferable to her than returning to in-patient treatment. It’s not that Chloe has become suicidal—if there were a way for her to maintain a healthy weight without being committed she would do so, but her disease is uncontrollable, and in her view, returning to in-patient therapy that never seems to work is no longer and acceptable option.

            Chloe’s requires has greatly upset her care team and her family. Her sister is adamant that she not be allowed to obtain the directive she wants and won’t agree to Chloe’s wishes as her healthcare proxy because she can’t bear the idea of her sister dying at such a young age and in such a tragic and preventable way. Chloe’s internist, Dr. Shankar, is also opposed to the directive, because he feels that 22 is too early for a person to give up on life, and that anorexia is a mental disease that renders Chloe incompetent to make such an important medical decision for herself. However Chloe’s psychiatrist, Dr. Snyder, insists that despite her disease, Chloe is sufficiently competent to make her own treatment choices.

Richard Mertek

Richard Mertek is an 88-year-old retired physician who has been hospitalized for the second time in three months with Lewy Body Dementia. In spite of the dementia, he is still able to carry on a conversation and answer questions about current events and perform simple math calculations. He is ambulatory with a walker and is able to dress and feed himself, but he has become incontinent. In addition to suffering from loss of cognitive capacity and motor control, this form of dementia is affecting Richard’s emotional stability. Unfortunately, Lewy Body dementia also causes paradoxical reactions to antipsychotic medications, so that sedative medications that could ordinarily treat his psychological symptoms would instead cause agitation and hallucinations. Richard’s unmanageable behavior has been problematic, to the point where he tried to choke a nurse under the delusion that his medication was poisoned.

            At this point, Richard is medically ready for hospital discharge, and psychiatric medications have been optimized. However, Richard’s doctors are family are struggling to plan his discharge. Because of his history of belligerent conduct, Richard has been rejected by more than 20 assisted living facilities and nursing homes. His elderly wife suffers from emphysema and may be developing dementia herself, and has refused the necessary healthcare aids that she and her husband would need to remain in their own home. None of Richard’s children are prepared to take their father into their own homes. Doctors are reluctant to release Richard to his home.

BB

BB was a thirty-seven-year-old woman, in good health, employed and pursuing martial separation. Without warning, she suffered a brain stem stroke in November, resulting in the diagnosis of locked-in syndrome. She was left fully alert mentally, although quadriplegic and unable to speak; she preserved limited voluntary head movement, vertical gaze, blinking, and minimal voluntary movement of her left arm. Before her stroke, BB had a history of major depression with psychotic features, with on previous psychiatric hospitalization ten years earlier. Over the past decade, her symptoms were well controlled with weekly psychotherapy and medications. She was an effective and skilled professional in a competitive technical field. Ten weeks after her injury, BB was transferred to a rehabilitation facility for possible weaning from a ventilator and assistance with communication and mobility. Here she learned to communication with a computer system and received a modified power wheelchair. After some difficulty, she succeeded in breathing without the ventilator. However, her success disappointed her, to the surprise of the staff. It was then that the medical team learned of BB’s wish to die.  BB told a psychotherapist that she was suffering, which was primarily psychological rather than physical. She did not believe that this could ever accept life with her extreme physical limitations. BB’s medical team encouraged her to reconsider, saying many who suffer catastrophic injury have suicidal ideas year only, but after a year or two often regain their desire to live.  BB initially promised to postpone the discussion for 6 months, but after three weeks she changed her mind and said she wanted to die by stopping all nutrition, hydration, and medications, except for morphine to control her pain. BB manifested significant fluctuations of mood since admission, but a psychologist noted that she did not appear to have depression or a formal thought disorder.

            BB’s attending physician felt he could not continue to act as her doctor if she wanted to terminate food and fluid. The physician described to BB his idea of the suffering she would endure as she died of starvation and dehydration. He would not offer her pain medication, for to do so, in his opinion, would hasten her death, in violation of his ethical and personal beliefs. The physician believed BB’s request was more akin to assisted suicide. BB is not a candidate for local hospices as her imminent death is her own choice. BB’s disability makes the option of dying at home and impossibility, as she would need significant assistance to manage pain, possible seizures and routine care.

LJ

Pentecostal beliefs. Her family brought her, under protest, to a large urban medical center when they discovered she walked with great difficulty. On her left food was an erosive and festering black mass, diagnosed as malignant melanoma. LJ stated that five years earlier, she first noticed this lesion, she had assumed it was a cancer. She had carefully concealed the lesion from her family because she had no desire for, nor belief in, medical care. Specifically, LJ was certain that doctors would want to amputate her foot, and she would never agree to such a treatment. LJ’s doctors identified a host of other medical problems, including a significant blood clot in her leg, a resulting leg infection, and fever. LJ accepted hospitalization and initial treatment, including hydration and antibiotics. After pathology confirmed that the lesion on her foot was malignant melanoma, the doctors told LJ that the required emergent amputation of her left leg below the knee. Without amputation, she might soon die from either the infection or a pulmonary embolus formed by the blood clot in her left leg. Amputation would also halt the spread of her melanoma if it had not already metastasized. LJ, however, refused amputation vehemently for religious reasons. Not convinced of the severity of her condition, LJ began to refuse blood draws, antibiotics and other medications.

            LJ has a close and supportive family of three daughters and one son, all of whom are alarmed she is refusing medical care, but only one of her daughters believes that the physicians should not allow LJ to refuse care, saying the choice is akin to suicide, that it is ‘crazy,’ and that she might go to court to force her mother to accept amputation. The staff caring for LJ also object to her refusal of amputation and to her reasons for it. Physicians believe she will have a 50% chance of survival for 5 years if she accepts the surgery. LJ has grown increasingly irascible at the medical staff, refusing them to speak to her and threatening to throw food trays at them if they bring up the subject of amputation. One doctor referred to her refusal as a tragic ‘delusional belief in the healing power of Jesus.’ Another doctor believes that if she refused treatment, she should be immediately discharged for fear of a liability should she suffer a rapid deterioration as a result of nontreatment.

--By Tia Powell

Jean McGuire

 Jean McGuire is a seventy-one-year old profoundly mentally disabled woman with the mental age of a two year old. A lifelong resident of a state institution, she was hospitalized because of a mild fever that resisted standard treatment.  She has been in the hospital for nearly three weeks undergoing a battery of invasive and uncomfortable diagnostic procedures: two bone marrow biopises, a barium enema, and a fine needle lymph node bipsy had all been performed, and their results had been inconclusive. Ms. McGuire has been placed with a PEG tube because she had been losing weight.  After some of her worst experiences, Ms. McGuire had been seen whimpering and crying for days. She spends most of her time in the hospital curled up in a fetal position, with the blankets drawn over her head. Before her hospitalization Ms. McGuire was reported to be capable of enjoying the company of others and enjoyed the facility she resided in. The director of her facility said that she reacted with obvious displeasure during even routine medical examinations, often needing to be held by an assistant. Though the physicians are unsure of her exact diagnosis, they suspect she has high grade large-cell lymphoma. Treatment for this would include six to eight course of chemotherapy with its burdensome side-effects. With treatment, up to 70 percent of patients have measure improvement of symptoms, but only 30 percent can expect long-term remission. Ms. McGuire’s physicians and facility direct wonder whether the treatment will do more harm than good.

Ian Bykovsky

Ian Bykovsky is a twenty-six-month-old child of recent immigrants from a former Soviet-bloc country. He had been a well child, but, because of fever and cough, he was taken for a pediatric visit. Physical examination and laboratory studies led to a presumptive diagnosis of acute lymphoblastic leukemia. Ian was admitted to the hospital, and the diagnosis was confirmed by bone marrow aspirate and biopsy.

            Communication with Ian’s parents is complicated because neither speak English. A family member who does speak English attended meetings between the physician and Ian’s parents, to interpret the explanation of Ian’s condition and the medical recommendations. They physician explained that standard treatment for Ian’s condition included one month of inpatient treatment with steroids and chemotherapy, followed by two years of weekly outpatient treatment with steroids and chemotherapy. A Broviac catheter would be necessary as well as a series of spinal taps.  The physician explained that with this standard course of treatment, Ian had an 80 percent chance of permanent remission. The physician also explained that the side-effects of the treatment would include hair loss and nausea, as well as some long term effects on Ian’s learning ability and heart function were possible, but they should be minor. Mr. and Mrs. Bykovsky decided they did not want this treatment and provided a number of reasons for their position. First, they said that the treatment would be a long and painful ordeal to put a child through, they were also concerned about the spinal taps. They were also afraid of being responsible for Ian’s home care, particularly using the Broviac catheter. They spoke of the easier acceptance of life and death in their native country, and how people there typically have large families, in part from an expectation that not all children would survive to maturity. In their country, people are less likely to rely on aggressive medical treatment when a grave diagnosis is given. Mr. and Mrs. Bykovsky could accept that Ian’s life would be shortened by their decision, but they preferred tat to subjecting him to the horror of treatment.  Furthermore, Mr. and Mrs. Bykovsky said that they were guided in their decision by the deep religious convictions of their Pentecostal faith, that the hand of God would decide Ian’s fate.  The Bykovskys are told that if there leave the hospital against medical advice that a child protective agency might authorize Ian’s treatment over their objection. They respond that they left a totalitarian state for America because of the promise of religious and personal freedom, and that this kind of interference by the state in their family’s life was exactly what they thought they had escaped. 

--by  Jeffrey Spike and Jane Greenlaw

Ben Garrett

Case of Ben Garrett: Cleft Lip and Palate[1]

Ben Garrett is an otherwise healthy 15-month-old boy born with a cleft lip and palate.  His mother left when he was just a few weeks old and Jordan has since been living with his single father, Mr. Garrett.  While he received he did receive standard vaccinations as an infant, Jordan did not pursue any other medical care for his son.  When Ben’s doctors brought up corrective surgery, Mr. Garrett would put off the conversation, saying “he’d think about it”.

Typically, corrective surgery is done between 6 weeks and 9 months to maximize the child’s ability to develop normal speech patterns.  Ben has already demonstrated speech difficulties, alongside other common effects of cleft lip and palate, including repeated ear infections and poor growth.  Doctors agree that while not ideal, Ben’s clinical prognosis without surgery is neither life-threatening nor severely disabling. He will, however, probably always have a noticeable speech impediment and have some minor trouble feeding. 

Concerned the child will soon be too old for surgery to have beneficial effects on Ben’s speech and growth, Ben’s physicians re-approach Mr. Garrett about corrective surgery at 15 months.  This time Mr. Garrett refuses outright, saying that prayer is much more effective at healing Ben than invasive surgery.   The risks of surgery are minimal to moderate with the only significant risk being a possible adverse reaction to anesthesia (5% chance of happening, but if it happens, it could be fatal for Ben).

Should the state intervene and mandate corrective surgery for Ben?

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[1] Author: E.K. Salter, PhD (2013). 

Bernice Mettack

Case of Bernice Mettack[1]

Adolescent Refusing Blood Transfusion Against the Wishes of His Parents

Bernice is a bright, thoughtful and outgoing 17-year-old female.  When she was 15, she became a Jehovah’s Witness, despite her family’s skepticism.   She has been a committed and faithful member of the church since her conversion.   At age 17, Bernice is diagnosed with immune thrombocytopenia, an autoimmune disease that interferes with the blood’s ability to clot.  As a result, Bernice’s immune system is attacking its own platelets, causing a low platelet count.  For the first couple weeks, physicians treat Bernice’s disease with corticosteroids, which slow platelet destruction.   However, her condition continues to worsen and doctors decide a blood and platelet transfusion is the most effective mode of treatment.  Bernice’s parents agree to the transfusion, but Bernice adamantly objects claiming that if she accepts blood products she will be forfeiting eternal life.  The medication alone is expected to be 35% effective at treating Bernice’s thrombocytopenia effectively, with minimal side effects.  The blood transfusion is expected to be 90% effective at treating Bernice’s disease, with minimal side effects. 

Should the physicians follow Bernice, and treat her only using medication, or should they follow her parents and force Bernice to receive a blood transfusion, against her considered wishes? 

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[1] Author: E.K. Salter, PhD (2013)

Colin Newmark

Case of Colin Newmark: Refusal of Chemotherapy for Lymphoma[1]

At three years old, Colin Newmark developed an aggressive and lethal form of pediatric cancer known as Burkitt’s Lymphoma.  Colin’s doctors recommended that Colin be treated with a heavy regimen of chemotherapy, stating that chemotherapy offered Colin a 40% chance at surviving at least eight more years.  Without chemotherapy, he would almost certainly die within one year.   His parents decided that instead of allowing an uncertain and painful medical treatment, they would take Colin home and seek prayer-healing through their church. 

Should the state intervene and compel chemotherapeutic treatment for Colin?

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[1] Author: E.K. Salter, PhD (2013), based on court case Newmark v. Williams/DCPS, 588 A.2d1108 (1991).

Kevin Sampson

Case of Kevin Sampson[1]: Surgery for Neurofibromatosis

Kevin Sampson is a 15-year-old boy with neurofibromatosis (also known as “elephant man’s disease”) which manifested as a large, bag-like benign growth causing one side of his face to be twice as large as the other.  Kevin had fallen severely behind in school and functionally illiterate, in part because he had left school at an early age, finding the taunting of his classmates to be unbearable.  Kevin’s mother refused to consent to the surgical excision of his growth not based on the operation itself, but the high likelihood that Kevin would need blood products during the surgery, which her Jehovah’s Witness faith did not permit. 

            Kevin’s neurofibromatosis is not fatal and only causes mild to moderate clinical problems (head aches, balance problems).  However, his physicians are more worried about the relational and emotional (and indirectly, intellectual) issues caused by the growth.  Removal and reconstructive surgery carries a 95% success rate of both removing the growth and restoring a normal appearance (with a small scar). However, there is a small but significant risk of complications from anesthesia (5% chance of a fatal reaction).  There are no alternative treatments for the physicians to consider. 

            When asked, Kevin states that he is desperate to have the growth to be removed.  He is tired of being ridiculed and shunned.

Should the state intervene and compel surgical removal of Kevin’s growth?

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[1] Author: E.K. Salter, PhD (2013). Based on In re: Sampson 278 N.E.2d 918, 1970.

Richard Johnson

Richard Jacobson is a thirty six year old man. He is currently living in a homeless shelter because he lost his job about two years ago. He previously worked as a construction worker, however, when a piece of the machinery fell and his brain was left permanently damaged, he was let go. Ricky, as he likes to be called, is functioning at about a sixth grade level. He is brought into the ER by the police after he is found wandering around the park one evening in nothing but his underwear. Ricky is known to the ER as a frequent flyer. He is an uncontrolled diabetic and his blood sugar levels typically reach astronomical values before he winds up back in the ER.

This particular evening is a January night in Chicago where is has recently snowed fourteen inches of snow. When Ricky is brought into the ER, he is only wearing only underwear, a hat and a tattered pair of shoes. The shoes are ones that the hospital gave him only a week prior to this current admission. As he is admitted to the ER, the nurses begin working him up, hooking up IV’s, and beginning a drip to lower his glucose levels. As they begin to pull away at the shoes that are frozen to his feet, they notice the intense frostbite in his feet. After Ricky’s blood sugar is brought down to normal levels, he is assessed by the attending in the ER using the mini mental state examination to determine if Ricky is competent to make his own medical decisions. Ricky is able to complete the exam scoring a 27, well within the limit for cognitive competency. Upon further examination, the attending in the ER also decides to call a surgical consult because even after rewarming, Ricky’s toes do not all return to normal states and are looking progressively dead.

Dr. Jablonsky is the surgical attending on call that evening and after an examination of Ricky decides that he is in need of surgery to remove the dead toes. This surgery has been deemed time sensitive but not necessarily immediate because the longer the team wait to remove the dead toes, the greater the chance that the team will have to remove the entire foot because of death in the bone or the muscles of the foot. However, as Dr. Greene, a resident under Dr. Jablonsky, is talking with Ricky about the surgery, he notices that Ricky is adamant that he does not want to lose his toes. He says that because he is homeless he needs his toes. He can’t live without his toes. Dr. Greene explains that if they don’t remove the toes he will lose one if not both of his feet. This doesn’t seem to impact Ricky, he just states again that he will not go into surgery and allow them to remove his toes. Dr. Greene brings this concern to Dr. Jablonsky, whose only response, is “consent the man or he will lose a lot more than his toes.” Dr. Jablonsky goes and talks with Ricky and returns with a signed consent form. However, when Dr. Greene talks with Ricky, he is concerned that Ricky might have been bullied into signing the form by Dr. Jablonsky.

When Dr. Greene suggests involving Dr. Rowland, the psychiatrist, in order to assess Ricky’s ability to make his own medical decisions, Dr. Jablonsky refuses stating that “Rowland is not a competent professional; she works so slowly that Mr. Jacobson will need his leg amputated before she clears him for surgery.” He also states that because of the mini mental state examination he is clearly competent to make medical decisions. Upon further investigation however, Dr. Greene discovers that Dr. Rowland and Dr. Jablonsky once had an intimate relationship that recently ended badly and he has been avoiding her since the breakup. Dr. Greene is concerned that Ricky is not aware of the consequences of his decision and will soon sign out AMA and eventually lose his foot or his leg due to gangrene. As Dr. Greene, how do you proceed?

--Written by Kate  Sulkowski

Amy and John

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Amy and John are a young couple with a five year old daughter Abby. Amy also has a nineteen year old son, Brian, from a previous relationship. They had planned on having a large family. Abby was diagnosed with leukemia when she was two years old. She has had three surgeries and is currently on the transplant list for a bone marrow transplant as well as a new kidney. A bone marrow transplant would most likely put her in remission enough to receive a new kidney. Abby is on dialysis six days a week and spends most of her time in the hospital. Abby has never been to preschool and hardly plays with children her own age, except for in the hospital daycare, when she is well enough to go there.

            Neither Amy nor John are blood matches for Abby. Brian left home when he turned eighteen, has not been tested as a possible donor, and has not made contact with the family for four months. No other close relatives are match for Abby.

            Prior to Abby getting sick, Amy and John discussed having another child. Now however, Amy and John approach Dr. Johnson, a fertility specialist, to help them have another child. They want to select various aspects of the fetus. Specifically, they want to select for a child that would have the same blood type as Abby in order to use the cord blood from the birth as a marrow transplant for Abby. They also hope that the new baby will be able to donate its kidney to Abby at a later date. During her initial meeting with the couple, Dr. Johnson notices that John does not talk much and when asked direct questions he tends to direct them towards Amy or answers with one word answers.

This concerns Dr. Johnson and she decides to sit down with Amy and John separately. When she talks with Amy, she can tell that this is their last option to save Abby’s life and Amy is clinging to the only hope she has left. Amy is well within child bearing years and having another child would pose no immediate health risks to her or the potential baby. Amy wants to begin this process as soon as possible and wonders exactly when they can begin. However, during her discussion with John, Dr. Johnson has to ask him a lot of questions before he finally blurts out that he is not alright with designing a child to be used to save Abby. He was raised a staunch Catholic and he believes that every life is sacred. He is concerned about the eggs that will be lost in the process and the potential lives they could have been as well as the idea that their new child will be used as a commodity. He states that he knows he and Amy will love the child regardless of the outcome but he is concerned about Amy’s motivations behind having this child. He is too nervous, however, to talk with Amy about his concerns and problems with the creation of their next child because he fears she will leave him if she thinks he is not on board. He is also afraid of the guilt he will feel if he does not do everything possible to save his little girl. However, he swears that he cannot tell his wife about his feelings and asks Dr. Robinson to keep them confidential. Dr. Robinson calls the couple into her office the next day to discuss the options available to the family. As Dr. Robinson, do you offer to help them create a baby with the desired blood type?

-Written by Kate Sulkowski

Brad and Dr. Robinson

Brad is a seventeen-year-old male with advanced cystic fibrosis (CF). Due to the present condition of his lungs, Brad has been given about three months to live. Brad comes into the ER with his girlfriend Jenny. Brad is unable to breathe. Dr. Robinson ascertains Brad’s age, after Jenny unwillingly gives it up, and intubates him. After Brad is intubated, his mother is located and called. When Brad’s mother Janice arrives, she informs Dr. Robinson that Brad has been living with Jenny in an apartment recently. Janice and Brad have recently been in a fight because of Brad’s decision to run away and live with Jenny (and not her). Dr. Robinson pulls Brad’s mother aside and tells her that there is a good chance that Brad will not wake up. His brain was without oxygen for an extended period of time and there is a good chance that he will not recover. Also, the amount of time on the ventilator did nothing to improve Brad’s condition and nothing can be done further to improve it. Dr. Robinson asks Brad’s mother about a DNR order and about her son’s wishes at the end of his life. Because of Brad’s adamancy about not being intubated when he originally arrived in the ER, Dr. Robinson is concerned about going against Brad’s wishes. Jenny also returns to the hospital with a non-statutory advanced directive stating that Brad did not wish for any heroic measures and under no circumstances did he want to be put on a ventilator unless it would improve his condition. Janice says she is not ready to lose him and says to intubate him again if necessary. Dr. Robinson looks at the advanced directive that Jenny brought in. Although this is a non-statutory advanced directive, and thus has no legal authority, Brad is extremely clear with his words. Brad wrote that he has watched numerous friends with CF die both on ventilators and on by choking to death on their own saliva and he never wanted to be in that situation. He never wanted to be on a ventilator and he wanted to spend the last days of his life with Jenny. He also wrote that his mother could not understand his feelings because she was blinded by her love for him and her fear of losing her only son. Dr. Robinson is concerned about doing what is best for Brad. Brad has a 2% chance of waking up to even a semiconscious state according to the neurologist’s assessment. He will continue to deteriorate on the ventilator and he will require ANH and a central line infusing his body with medication to control his pain. Taking into consideration the wishes of Janice, Brad’s legal guardian, and the advanced directive Brad wrote prior to his hospitalization, how should Dr. Robinson proceed?

--Written by Kate Sulkowski

Mrs. Klein and Baby A

A very premature baby, Baby A, has been under your care since birth. Her mother, Mrs. Klein, was forced into an early cesarean delivery because of the baby’s condition.  Baby A was born with a very severe form of hydrops fetalis, a condition that causes her to suffer from breathing problems, risk of heart failure, total body swelling, extreme anemia, and bruising all over her skin. She has been on many medications to prevent heart failure and is on a ventilator to manage her respiratory problems. However, even after having oxygen delivered to her body, she shows no signs of improvement and her oxygen saturation levels remain low. Furthermore, because she was born premature, the lung tissue is underdeveloped, and her lungs cannot provide enough oxygenation. You, as the physician, are concerned of causing oxygen toxicity by administering more oxygen and causing more harm than benefit to Baby A. Also, since her condition is worsening, you will have to administer more medications to prevent heart failure, brain damage, and lessen the respiratory complications, but you also know that combining many of the medications and treatments has shown to result in more pain and poorer quality of life. The prognosis is very bleak, but her parents insist on treatment in spite of the lack of improvement and the chance of furthering the child's suffering.
During a meeting with Mr. and Mrs. Klein, you explain to them the burdens of the treatment. However, Mrs. Klein interrupts you.
“We want everything done to keep our baby alive,” Mrs. Klein urges. “We come from a religious family, and we believe that God created human life. It is not acceptable to take away a life that God has created. You have to do everything that you can as a doctor to save people’s lives, not end them.”
What should you do?


-Written by Kiran Singh

Mr. Busey

Your patient, Mr. Busey, is a 77-year-old man who has been on a treatment for AIDS known as HAART, highly active antiretroviral therapy. However, because he has not been taking his medication daily, the HIV has become resistant to the combination of HAART. He has missed many of his regular check ups with you. One day he showed up and informed you that he does not want to pursue any more treatment. He plans to live the rest of his life without any concerns about his health. However, he also informed you that he has a new girlfriend, Ms. Cleary, that he met at the senior home. He also informs you that he has not told Ms. Cleary about his AIDS. You feel a little uncomfortable, but you ask him if he is sexually active. To your surprise, he responds that he is. You begin to talk to him about safe sex practices, but he interrupts saying “we’re just a couple of old geezers. “It doesn’t matter anyways because we aren’t planning to have children.” He shrugs it off and says that he just wants to enjoy himself for the rest of his life. “Anyways, Ms. Cleary has a lot of other medical problems to worry about. She does not need this on her mind, and it would not affect her health much.” You are concerned of the patient spreading the AIDS, but you also know that informing the girlfriend about his AIDS breaches confidentiality. Also, you research a little more about the medical conditions that Ms. Cleary has, and you realize that the even if she did contract AIDS, it would not affect her lifestyle much. However, you also feel a little uneasy because you realize that she may want to know as a precautionary measure. You do not want to breach your patient’s confidentiality, and you are unsure whether or not there would be a benefit of informing Ms. Cleary of her boyfriend’s condition. What should you, as the physician, do?

--Written by Kiran Singh

Tim L.

You are a pediatrician at a family practice. A father, Mr. L, brings his 12-year-old son, Tim, to your office because his son has had a slight fever and other flu-like symptoms. You are told by the translator that the family emigrated from Vietnam a couple of years ago and are becoming accustomed to their new lives in America. However, in spite of their attempt to assimilate, they uphold and value many traditions from their culture.

During the routine check-up, you ask the son to remove his shirt. You observe bruising in a pattern across his back. You ask the translator to question the father about the bruises, and he explains that Mr. L’s wife, Mrs. L, performed cạo gió on their son. The translator continues to convey Mr. L’s message to you on how cạo gió involves oiling and firmly rubbing the skin with a coin in order to restore balance in the body. He further reveals that the family believes that an excess of “wind” causes many illnesses and how cạo gió, or “catch the wind,” is a method of raising the blood to the surface of the skin and releasing this bad wind. He also explains that this is a common practice in Vietnamese families to improve mental and physical wellbeing.

After discussing these alternative medicine practices with Mr. L, you return to your check up with Tim. When you place your stethoscope on Tim’s tiny back, he winces in pain from the bruises, which concerns you. Should you report the parents to the Child Protection Agency?

--Written by Kiran Singh