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.

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.

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