Case 1:

An 86-year-old female patient admitted to hospital due to an increasing inability to cope at home and recent fall in which she suffered a broken hip. She has previously been diagnosed with COPD, hypertension and increasing cognitive deficits. While in recovery in hospital, an abdominal mass has been found (malignancy suspected but not confirmed), she has had a decrease in her ability to care for herself, difficulty swallowing with increasing aspiration risk, early stages of renal failure and an exacerbation of her cognitive issues. The patient does not have a formal Advance Directive nor has she assigned a Power of Attorney. She has three daughters and one son who is a cardiologist and lives out of the province. The daughters have demanded that the patient be a full code, requested that transfer be made to ICU with a PEG tube placed and dialysis started should it be required. The son phoned you over the weekend and stated that given his mothers age and complex medical situation he expects that she would be provided symptom management and comfort care but that no aggressive measures should be undertaken to interfere with the natural decline and progression of his mother’s diseases. He has requested regular updates regarding her status and any interventions or treatments proposed.

What are some of the ethical issues in this case?

  • Does ‘increasing cognitive defects’ = lack of capacity?
  • Are any ethical principles in conflict? Autonomy? Beneficence? Nonmaleficence?
  • Can an SDM demand treatment?
  • Who is responsible for proposing a plan of care?

 

Case 2:

Mrs. Beaudoin, who is 97 years old, was admitted to your LTC facility 6 years ago. Shortly after becoming a resident, she suffered a cardiac arrest and was found to be unresponsive by the staff; CPR was initiated for a total of 20 minutes prior to return of spontaneous circulation. She has an advanced directive stating that she agrees to “transfer to an acute care facility”, but other options, such as CPR and intubation, were not explicitly addressed in this document. She has no formal Power of Attorney.

Initially, Mrs. Beaudoin had lived at your facility watching TV for most of the day. She was wheelchair bound and required assistance with most activities of daily living (ADLs). Her husband lives at your facility with her and is quite frail with moderate dementia. Mrs. Beaudoin is frequently visited by her large extended family, which comprises 4 children and 5 grandchildren. She is known to have cancer throughout much of her body, moderate dementia, a very bad heart, and type-2 diabetes.

After her cardiac arrest and a short stay in the Hospital ICU, Mrs. Beaudoin is brought back to your facility able to breathe on her own, but with a moderate -severe brain injury caused by lack of oxygen after her cardiac arrest; this has left her unable to communicate in any meaningful way with others. She is receiving thickened fluids as her source of nutrition and hydration, but is only able to consume about half of the calories that would be needed to keep her at her current weight. Unfortunately her health begins to decline further shortly after returning.

The team decides to hold a family conference with the resident’s children, and proposes a plan of treatment that would focus on comfort care only, excluding CPR if needed again. The patient’s eldest daughter does not agree and states that her mother is “a fighter” and wanted to live to be 100 years old so that she could receive a letter from the Queen. The daughter asks that her mother be transferred back to the acute care hospital to receive the care of “experts” and so that she could be seen by a surgeon for surgery and chemotherapy for her cancer.

The treating physician discusses the case with the intensivist on call at the hospital over the telephone. The intensivist agrees that the prognosis is extremely poor and likely the resident would not benefit from further invasive treatment. The intensivist at TOH holds a family conference with the family and team at the LTC home over the telephone. He identifies himself as an expert in the field. The older daughter, reiterates their requests to the intensivist.

What are some of the ethical issues in this case?

  • Who is the appropriate substitute decision-maker (SDM) in this case?
  • If there is more than one SDM, what should you do if they disagree?
  • Because we know Mrs. Beaudoin’s desire to live to be 100, must we ensure that “everything is done” in an attempt to prolong her life?

 

Case 3:

Mr. Wilson, a 51 y.o. male patient, is admitted to the Intensive Care Unit in critical condition after a motor vehicle accident. He presented unconscious and is therefore unable to make his own medical decisions. The family of this patient provided a detailed formal advance directive which indicated that in the event of a traumatic injury such as this one, where the outcome is uncertain, the patient would consent to aggressive medical intervention in an attempt to stabilize and determine the severity of his injury. Life-sustaining interventions were therefore pursued.

After a myriad of test and a set of neurologic assessments were performed, it was determined that an anoxic brain injury occurred and it was not clear whether the patient would ever regain consciousness. The team needed some time to clearly establish a diagnosis, and the family members were kept informed of any progress that was made.

Several weeks passed as the patient stabilized, and the health care team was finally confident that the patient had met the criteria for being in a Persistent Vegetative State, a diagnosis that was presented to the family. According to the advance directive, if the patient were ever in a situation where their continued existence would be in such a state, he would want all life-sustaining intervention withdrawn, and be allowed to die. The family (spouse is no longer in the picture, 18 y.o. daughter, 20 y.o daughter, and 14 y.o. son) are presented with this formal diagnosis of PVS and are willing to continue to assume the responsibility of SDMs. The 14 y.o. son is adamant that his father is a ‘fighter’ and demands the team continue to ‘do everything possible’, and provide the most aggressive care they can. The 18 y.o. daughter agrees with the son, but the 20 y.o. daughter wants to respect her father’s wishes and refuse further life-sustaining measures.

What are some of the ethical issues in this case?

  • Who is(are) the designated SDM(s)?
  • Who do we listen to when they disagree?
  • Can the SDM(s) consent to a decision that would mean the death of the patient?

 

Case 4:

A 75-year-old healthy male was working on the roof of his house when he slipped and fell 10 ft. to the ground. He was knocked unconscious. When the paramedics arrived he was awake but confused. His vital signs were stable (e.g., Glasgow Coma Scale [GCS] score of 14). He was immobilized with a C-collar and backboard and taken to the ED. Shortly after arrival in the ED he became more confused, then sleepy. His GCS score decreased from 14 to 10. The attending emergency physician was concerned that perhaps the patient had a significant head injury and was in the process of arranging for a CT scan when the patient’s wife arrived. The patient’s condition continued to deteriorate, to a GCS score of 8. The emergency physician prepared to intubate him, but when she discussed this with the patient’s wife, the wife became upset and stated that her husband had a “living will,” which specifies that, if he became critically ill, he would not want any resuscitative interventions, including intubation.

*From: Pauls, M. et al. (2002). Ethics in the Trenches: preparing for ethical challenges in the emergency department. CJEM, 4:1, Pg. 45.

What are some of the ethical issues in this case?

  • Was the patient adequately informed when they declared their wishes? Did they put these wishes into a particular context? That is, were they intended for reversible, or irreversible illness?
  • Is the patient’s wife required to make a decision in the best interests of the patient? Who decides what is ‘best’?

 

Case 5:

73-year-old female admitted to hospital with aspiration pneumonia and sepsis.  Past medical history of multiple CVA’s, PEG tube feeding, multiple pressure ulcers.  Patient able to open eyes but not able to follow any commands or respond verbally.  Patient came to hospital from home with her wife.  On admission, the wife was adamant that the patient be a full code. Wife seemed to be unclear regarding patient’s current medical/functional condition, and the health care team felt that due to unrealistic expectations of the wife, the patient was suffering.  The team was struggling with the goals of care that were demanded. Goals of care were only changed when a new physician took over the care of the patient, and was willing to intervene.

What are some of the ethical issues in this case?

  • Must the physician/health care team acquiesce to all demands by a substitute decision-maker? What were the reasons she provided for wanting “full code”?
  • What would the patient want in this case if she could tell the team? What would it mean to support her wishes?
  • What reasons were given by the first physician to not make the patient full code? And from the second physician for agreeing to full code?