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and his wife and primary care physician want to be put him into palliative sedation and have his feeding tube withdrawn.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

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. 

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

Deborah

Deborah is a sixty-eight-year-old patient with advanced dementia.  Her appetite has slowly decreased over the past two months, and had a particularly low appetite the past five days.  The care team at the nursing home has offered the option of a percutaneous endoscopic gastronomy (PEG tube) to help provide nutrients she is not getting from oral intake.  Dr. Johnson explains that the benefits are limited in this case with dementia.  He explains that the patients often try to pull out their tubes in their diminished conscious state.  Dr. Johnson leaves the decision up to her children, Robert and Ann, along with her sister Betty.  Robert and Ann agree that the feeding tube should not be placed, stating that their mother is gone, she is no longer the tough woman they know to be their mommy.  Robert states that it would be best to simply let nature take its course, if she is meant to die.  Betty is outraged at their decision.  She yells how can you let your mommy starve to death, she is a fighter would not want to die.  Betty argues that Deborah is a devout Catholic, and that her sister would have wanted the feeding tube, because she believed all life was precious.  No one can argue against Deborah’s belief that she valued all forms of life, which was clearly indicated by her strong stance of supporting pro-life movements.  However, her children still believe that the feeding tube should not be placed, because they believe their mother would be harmed more than she would benefit from the feeding tube.

            Before Deborah entered the nursing home, her children lived several hundred miles away and only got to see their mother several times a year, during holidays and birthdays.  During these times, Deborah refused to discuss her opinions about the early signs of dementia, and her health, stating she did not want to ruin the fun memories, and dampen the event.  However, Deborah and Betty have always been particularly close.  The two of them went to mass twice a week for the past ten years leading up to Deborah’s placement into the nursing home.  The past three years, while Deborah has been in the nursing home, Betty still made it a priority to visit her sister several times a week, especially on Thursday nights for bingo.  Betty also has seen how much Deborah has enjoyed the programs the nursing home puts on during the week, along with spending time with her friends at the nursing home.  Should Dr. Johnson place the feeding tube?

--Written by Amanda Zinger

Mrs. K

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Mrs. K, a chronically debilitated and bedbound 86-year-old woman, was admitted to the hospital with an acute change of mental status. At baseline, the patient was alert and oriented but required assistance with all activities of daily living except feeding herself.. The patient had declined surgery for both the aortic stenosis and the hip fracture.

The patient, widowed in the 1970s, has one adult child, John, and lives by herself.  For 18 months prior to this hospitalization Mrs. K had paid for an around-the-clock caregiver, but in recent months the caregiver's hours had been reduced to 6 hours a day (9AM to 3PM) because of financial limitations. During the evening and overnight, Mrs A was by herself. To pay for caregivers, the patient had taken a reverse mortgage on her home, sold most of her belongings, and used credit cards to their limits.

Her son, who is 57 years old, is her designated health care agent and the only family member involved in her care. He visits periodically to check on Mrs. K, but these visits and his ability to provide assistance are limited by frequent travel and work obligations (he is a semi driver).

About 8 months prior to admission, a meeting was convened to share concerns with the patient about her safety. Participants included a social worker from Adult Protective Services (APS), her son, her EHCP physician (also her primary care physician), and an occupational therapist. The APS social worker was involved in this case for 2 years and had tried, along with Mrs. K's son, to arrange for her to move into an assisted-living facility (to be financed through a Medicaid waiver), but Mrs. K declined. Occupational therapists had worked with the patient for more than a month to see if she could become more independent, hoping to improve the safety of her home situation, but she remained chiefly bedbound. The patient was told by the assembled multidisciplinary team of professionals that her current arrangement was unsafe and that it placed her at higher risk of developing various medical problems and eventually clinically deteriorating. According to her EHCP physician, the patient clearly understood what was at stake: her Mini-Mental State Examination score was 28 of a possible 30, and, more importantly, she had the capacity to understand the risks. The patient's response to being confronted by the professionals was telling them, “You'll have to drag me kicking and screaming out of the house if you want to put me into a nursing home.” The EHCP physician and her son confirmed that this position was consistent with the patient's previously and repeatedly expressed views on the topic.

In the emergency department, she presented wearing a hospital gown, was oriented only to person, and was considered delirious. She was unkempt, had extensive dental decay and a small stage 2 ulcer on her buttock, and was lying in stool and urine. She was given intravenous antibiotics and rehydration. By hospital day 2, she was markedly improved, her mental status was considered to be back to baseline, and discharge planning was initiated. The physical and occupational therapy team recommended a short-term, subacute rehabilitation placement.

Mrs. K is not interested in rehabilitation and wants to go directly home as soon as possible; going home and staying at home is her foremost priority. Given their insights on the patient's home situation, members of the health care team, including social workers, physical and occupational therapists, physicians, and nurses, are concerned about her safety if she were to go home in her current state. She was told that she would likely become sicker, develop worsening bedsores, and have poorer hygiene. She was told that her chances of quickly returning to the hospital or even of dying at home alone were high. In addition, she was informed that her ability to secure in-home caregiver services would end when her money ran out. Although these concerns were shared with the patient, she remains adamant about going home, stating that she is aware of the potential risks and that she is not going to go anywhere else. The medical team thought she had the capacity to make this decision but, given the gravity of the situation, consulted the psychiatry department for a second opinion. After two evaluations, the psychiatric consultant concluded that the patient is competent, but she noted:  “the patient may not fully realize the extent to which her health has deteriorated and her increased need for care. There is uncertainty about how thoroughly the patient has thought through the ramifications of going home. During the evaluation interview, the patient seemed either unwilling or unable to engage in a careful (and adequate) conversation about the risks associated with her proposed course of action.” The psychiatric consultant indicated that the patient's depression was adequately treated.

Mrs. K’s strongly expressed desire to go directly home and not to a rehab facility appears consistent with her long-standing expressed wishes.  Communication with her son revealed that Mrs. K’s attitude toward “nursing homes” stemmed from a time in her life when she volunteered with a seniors’ facility. In doing this, she visited several nursing homes and developed an unfavorable view of them, insisting she never wanted to go to one. Accordingly, her son explained, past efforts to have her consider assisted-living options were always unsuccessful.

*http://www.hopkinsbayview.org/medicine/residency/files/grandrounds/Carrese_RefusalOfCare.pdf