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and his wife and primary care physician want to be put him into palliative sedation and have his feeding tube withdrawn.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

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.

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.