HSCI 414 CSUN Ethical Dilemma & Decision Making Law Discussion

Please answer with at least a page and a half and use power points to answer the questions.

Background: Mrs. C is a 67-year-old woman who was diagnosed as having non-resectable colon cancer six months ago. When that diagnosis was made, it was clear that the patient would eventually die but it was, understandably, not clear exactly when. This is the most recent of several admissions from a nearby nursing home for episodes of sepsis (infection) believed to be secondary to the entrance of bacteria through the friable colon cancer. On admission, the patient’s general health appeared to be poor. Mrs. C looked emaciated with generalized edema (swelling) and skin excoriation (abrasions). She could not move her legs and had only gross motor movement of her upper extremities secondary to severe spinal disease. Mrs. C communicated mainly by head movements such as nodding.

The patient was given antibiotics and steroids for treatment of the sepsis and made a “full code” based upon discussions with her. She said that she wished to be resuscitated should the need arise – she wanted “everything done.” Three days after admission the patient developed acute shortness of breath and a chest X-ray led to a differential diagnosis of congestive heart failure vs. pulmonary embolism. Mrs. C also developed acute GI bleeding believed to be secondary to the colon cancer. Over the next few days, diagnostic tests gave no additional insight into the patient’s condition and Mrs. C continued to become lethargic and confused. (This could be accounted for in several ways including possible brain metastases from the cancer.) Her oxygenation was poor. Thus, she was intubated and admitted to the ICU.

The patient also developed a pleural effusion and further malignancy was suspected. She became septic and pneumonia was thought to be the likely culprit. The daughter, Jane, was asked what the medical team should do and she, like her mother upon admission, requested that “everything be done.”

Over the next few days aggressive vasopressor therapy was begun to try and offset her dropping blood pressure. Nevertheless, pressure continued to drop and ranged between 30-40 systolic on maximum vasopressor therapy. Over the next 24 hours, the patient became anuric and developed massive generalized edema. She was oozing serous fluid from her skin and other puncture sites.

Dr. Smith called the ethics consultation service.

Dr. Smith: Dr. Smith, believing in the concept of a “good death,” would like to stop all aggressive treatment at this point and is extremely uncomfortable with the fact the Mrs. C’s daughter is asking “for everything” to be done. She would like to stop the vasopressors and when Mrs. C arrests (which Dr. Smith thinks will be within a day or two), she would like to not code her, i.e., make her DNR. Dr. Smith is treating the sepsis and doesn’t strongly feel one way or another about that although she would just as soon stop all antibiotics. Dr. Smith really doesn’t want to extubate the patient. She thinks that the patient would die very quickly thereafter, and she would feel like she had “killed” her even though she knows that isn’t true ethically. She is also conflicted about the patient dying while in her care since it might reflect on her skill as a physician. (She is concerned about her “batting average.”)

Jane – Patient’s daughter: Jane wants to give her mother every chance to recover. She says, “She’s a fighter and has pulled through these hospitalizations before.” People keep asking her what her mother would want. When her mother was first admitted, she said she wanted everything done. So, Jane cannot understand why people keep asking her this question. Jane doesn’t want to make her mother suffer any more than is necessary if there is absolutely no hope. But, when this becomes the case she doesn’t want the health care team to do anything that is painful to her mother. She asks, “Shouldn’t my mother get the stuff that doesn’t hurt, e.g., medications, food and water, etc?”

Assignment: You are the bioethicist called to respond to the consult request. Your hospital, Northridge General, has no explicit futility policy. The hospital policy manual contains a statement that physicians are not obligated to provide futile treatment. However, the hospital’s preferred approach is clearly consensus decision making with the family.

Please write an ethics review of this case. Your review should consist of two parts:

(1) An assessment of the ethical issues at stake in this case. What are the issues in this case and how would you analyze them? Whose rights and interests are in tension? You should consider in your deliberations the full range of ethical concerns presented by this case, including those pertinent to Mrs. C, Jane, Dr. Smith and Northridge Central. Insights gleaned from class readings, handouts and discussions should be evident in your assessment.

(2) Your recommendation to Dr. Smith and Northridge General as to how to proceed in this particular case. You are free to consider in your recommendations an immediate resolution of the case at hand as well as potential recommendations for how the hospital ought to handle potential, future similar cases from an ethics perspective.