Mr. Thompson

As a second-year neurology resident, Dr. Johnson has been fascinated by the case of Mr. Thompson, a construction worker who was nailing shingles to a roof when his co-worker's gun slipped, lodging a nail deep into Mr. Thompson's frontal lobe. Although comatose at first, Mr. Thompson regained consciousness and function under Dr. Johnson's care. is as important as the decision he or she reaches.

Despite his physical improvements after this accident, everyone in Mr. Thompson's life agreed that he was "not himself." Previously a gregarious, sunny man, according to his family and friends, he had now become surly, withdrawn, and disinhibited. Before the accident Mr. Thompson loved having his friends and family around; now he threw everyone out of the room at the slightest provocation, all the while cursing and screaming. Happily married to his wife for 27 years, Mr. Thompson had three children and no prior history of medical or psychiatric disorders. After his accident, however, he disparaged and insulted his wife when she visited and refused to see his children. He had a living will in the chart in which his wife was named as his health care proxy. During his recovery from the accident she had made decisions for him.

When Mr. Thompson had made good progress in his physical recovery, the neurosurgery team brought up the topic of removing the nail lodged in his skull, presenting the risks and benefits of the surgery to Mrs. Thompson. Even though the operation would be tricky, the surgeons firmly believed that the benefits outweighed the risks. Mrs. Thompson opposed the surgery, but Mr. Thompson was adamant about going ahead with it.

Dutifully, Dr. Johnson assessed his patient's capacity. Mr. Thompson was alert and oriented to person, place, and time; he passed the cognitive exam with flying colors. He verbalized understanding of his situation, stated clearly his treatment options and the risks and benefits of his surgery. He appeared to meet all the clinical benchmarks for decision-making capacity, and he was adamant that he no longer wished for his wife to be his health care proxy.

Dr. Johnson asked his team what they thought. The junior resident said, "the guy has a traumatic brain injury. He's literally not himself—he's a different person. He's impaired. That's the bottom line."

"I disagree," the senior resident said. "He's clearly oriented and capable of abstract reasoning. Personality changes don't mean you can trample on his autonomy."

*http://virtualmentor.ama-assn.org/2008/03/pdf/ccas1-0803.pdf

Mr. Archer

Forsythe Archer, a successful scientist with exacting standards and rigid personality, is being given palliative treatment for cancer.  During the course of the relapses and remissions of the disease, MR. Archer has steadfastly refused to discuss his illness with his two teenage children and has barely discussed it with his wife.  He has made her promise to keep it a secret.  His treatment program with its ups and downs has caused severe and unpredictable mood swings, which have exacerbated the children’s emotional problems.

            In an effort to help the children cope with their father’s behavior, Mrs. Archer wants to break the promise and tell the children what is happening.  However when she suggests this to him he angrily rebuffs her.  Mrs. Archer believes his refusal is causing undue distress and she fears for the emotional health of her children; one daughter in particular has been showing serious tendencies toward self-destructive behavior.

            In desperation, she pleads with the family doctor to do whatever he can – even use coercion if necessary – to get her husband to ‘open up,’ lest his cancer destroy not only his life, but the life of one or more of his children.  What should the physician do?


*Levine, Carol, ed. Cases in Bioethics: Selections From the Hastings Center Report. New York: St. Martin's Press, Inc., 1998.

Mrs. Burke

"Let's pause here," said Dr. Lawrence during morning rounds. "This is Mrs. Burke's room. She's a 78-year-old woman who came in for a knee replacement 4 months ago and was re-admitted a month later with fever, weakness, and Staph. aureus bacteremia. She continues to have bacteremia. We have done a complete work-up multiple times, but we've yet to find the source of her infection. She's been back to the OR twice on the recommendations of the infectious diseases consultants, but the orthopedic surgeons have stated this is not coming from her knee. Mrs. Burke has also had imaging of her spine and knee five times, an echo of her heart three times, and almost daily blood cultures. She has been on several antibiotics, all based on susceptibilities. Today we will have our fourth family meeting. Mrs. Burke's daughter is very expressive of her own wishes and requests, which lately do not seem to be correlating with her mother's, and we have found that regular family meetings help to keep everyone on the same page."infection

After he finished his report, Dr. Lawrence led the team into Mrs. Burke's room, and Mrs. Burke asked about the day's plan. "Are you going to poke and prod me again or will I finally get a little peace?" Dr. Lawrence replied that her anemia, a possible side effect from the antibiotics, was slightly worse and that Mrs. Burke had the option of waiting until tomorrow to recheck her blood counts or receive a blood transfusion that day in the hope of making her feel better.

Mrs. Burke replied, "Dr. Lawrence, I'm so tired of everything. I don't want the transfusion. I want to be left alone for a while. I really just want to go home."

Later that morning during the family meeting, Mrs. Cominsky—Mrs. Burke's daughter—said, "We want everything possible done to locate the source of my mother's infection so that we can eradicate it. If that means more labs, running more tests, getting more fluid samples, doing more MRIs and echoes, don't hold back! I want my mother to get well."

Dr. Lawrence looked at Mrs. Burke, who sat quietly by her daughter's side. "Is this what you want?" he asked.

"Of course that's what she wants!" Her daughter exclaimed. "She wants to get better!"

"Well, we had a discussion earlier today, and your mother indicated that she was not interested in undergoing more tests. She has been here for several months now, and, understandably, she is tired. Her preferences—and you can correct me if I misunderstood you, Mrs. Burke—are to hold off on further testing right now and to possibly...."

"My mother is sick! She is not clear-headed! Of course, she wants everything done!" interrupted Mrs. Cominsky.

Dr. Lawrence asked Mrs. Burke to state her preferences so that everyone knew what she wanted, but Mrs. Burke simply shrugged her shoulders and replied in a defeated tone, "My daughter takes care of me at home. She knows what's best."


*http://virtualmentor.ama-assn.org/2008/06/pdf/ccas1-0806.pdf

Dorthea

Dorthea is a 69-year-old woman who was well and active until about five years ago when she developed diabetes.  She was admitted to the hospital 18 months ago with recurrent fainting and was found to have an intermittent transient heart block.  She reluctantly consented to insertion of a permanent pacemaker. 

Three months ago her kidney function was found to be diminished to about 10% of normal, probably caused by her diabetes.  It was expected that she would soon require dialysis.  However, her kidney function has since improved so that dialysis will not likely be needed for some time.  She has since said she would refuse dialysis even if it were needed, and she has refused treatment of her profound anemia.  She did consent to a colonoscopy last month to see if she had cancer (malignant change was found in one small area, presumably cured).  She is now asking that her pacemaker be turned off so that she can die.

The ethics consultant met with the patient and two of her daughters.  Dorthea says she wants to die now because (a) she misses her husband who died three years ago after 45 years of marriage; they were very close, did everything together, and she says she can’t live without him; (b) she can’t stand to live in their home (memories), but refuses to move; and (c) she wants to “set her children free.”  She has resisted attempts by her three daughters who have encouraged treatment, including grief counseling, and have even offered for her to live with them.  She has guns in her home and knows how to use them, but she says she is unwilling to take her own life.  She is an inactive Methodist.  She says her only pleasure is having her children, grandchildren and great-grandchildren visit, but she feels her misery is also making them miserable.

The patient says she was told when the pacemaker was inserted that it could be shut off whenever she didn’t want it.  It is her impression that she will die quickly without it, however, her cardiologist expects this would not be the case.  Though she demonstrates no intrinsic rhythm when the rate of the pacer is turned down to 30 beats/minute on testing, most patients do develop some rhythm after several seconds of not beating at all.  Thus she might not die, but could suffer symptoms of congestive heart failure with an unknown outcome.  She says she is miserable, is not eating (though her weight is down only 5-10 pounds), and cannot care for herself or her home, but she doesn’t want treatment for her anemia or her grief.  When asked, she said she did not have the colonoscopy last month in order to protect her life.  The only reason she consented to the procedure was that she hoped it would show she had cancer that would end her life. 

Her daughters have run out of ideas for helping her, and are now supportive of her request.  They believe “she wants quality of life over quantity of life,” but they recognize that she is refusing treatment which could enhance her quality.  They realize she has not dealt with her grief, but are convinced that she never will.

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*http://cbhd.org/content/it-permissible-shut-pacemaker

J.R.

            J.R. is a combative 21-year-old female who presents in the emergency room disoriented, with a fever, chills, and a cough.  J.R. is well known by the medical staff.  She has had three previous admissions with endocarditis and twice has left the hospital AMA.  On her most recent previous admission her mitral valve was replaced with a porcine prosthesis.  J.R. is HIV positive and has a history of prostitution and substance abuse.  She refuses counseling. On the 12^th day of her hospitalization, J.R. leaves AMA even after her physician warns that the bacteria in her blood is still active.  Two days later she returns to the ER and it is obvious her heart valve must once again be replaced.  J.R. demands another valve, saying it would violate her civil rights to be refused. Would it be wrong to refuse J.R.?

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*Crigger, Bette-Jane. Cases in Bioethics : Selections from the Hastings Center Report. 3rd ed. New York: St. Martin's Press, 1998.

Mr. Simmons

            Otis Simmons is a 58-year-old homeless man living on the streets. One day he walks barefoot in the bitter cold through the streets of Manhattan in order to reach Roosevelt Hospital. “I froze,” he later said.  “I sat in one place 15 hours.” After he was hospitalized, he developed gangrene in his badly frostbitten feet.  The doctors wanted to amputate the infected portions, noting that otherwise the condition could become ‘life-threatening.’ Simmons refused the treatment: “My two legs got to say on.  I won’t have the operation.  I got to cure my own self.”

            Soon after, despite objections from hospital physicians, a State Supreme Court justice ruled that Simmons was legally competent and had the right tot refuse the amputation.  Antibiotic treatment helped to stall the infection.  However, Simmons finally lost two toes on his left foot and part of his right foot.  The bill for his three-month hospitalization amounted to $29,000 and has been submitted to Medicaid.  A hospital spokesman has said, “We don’t know how much they will pay or when they will pay it.”

            Mr. Simmons returns to the hospital 1 year later with frost-bitten hands.  Again he refused an amputation.  What should the hospital do?


*True Story

Mrs. A

            At the age of 70, Mrs. A has been admitted to the hospital for the fifth time in as many years for treatment of respiratory difficulty.  The last time she was in the hospital she had nearly died  She has severe emphysema, and when she developed a cold, her deterioration was so rapid that only artificial respiration in the emergency room saved her life.  However, it proved very difficult to wean her from the respirator. She spent 4 weeks in the Intensive Care Unit and required constant care from the medical staff, principally Intern B.  After she was discharged, she remained short of breath even while watching television.

            Now, 5 months later, she has contracted another cold, but this time Intern B has managed to treat her without resorting to the ICU and the respirator.  During her illness, Mrs. A’s two sons have been in constant contact with the medical staff.  They have been anxious, agitated, and demanding.

            It is now 2 a.m. and Intern B is again called to see Mrs. A, who is becoming increasingly lethargic.  It is obvious that she is in respiratory failure, and will probably die before morning if she is not given a respirator. However, hospital policy requires that respirators be used only in the ICU, where the required supporting staff and facilities are available.  There is only one bed open in the ICU.  The residents like to save one bed for an emergency.  As Intern B approaches, Mrs. A’s sons are waiting. He knows their questions:  What’s wrong now?  What will you do?

*

-->Crigger, Bette-Jane. Cases in Bioethics : Selections from the Hastings Center Report. 3rd ed. New York: St. Martin's Press, 1998.