Case for Ethics Questions:

John is a critically ill 82 year old man who has been in the hospital under your care for the last month. Early in his hospital stay, John was in a comatose state, for weeks, with respiratory, liver, renal and congestive heart failure. He responded only to painful stimuli, was intubated, and was on dialysis.

 

His family was heavily involved in his care and felt strongly that everything possible should be done to prolong his life. They believed that sedatives and pain medications would reduce his chances of waking from the coma and wanted them withheld. The housestaff, however, believed that he was experiencing pain and felt that his comfort should be highest priority.

 

After numerous family meetings and extensive social work involvement, an ethics consult was requested. The ethics committee agreed that withholding pain medication from John was unethical and cruel. When the case was then taken to administration, however, they overruled the committeeÕs decision and on the advice of hospital counsel, mandated that the housestaff follow the wishes of the family. Many of the staff involved felt frustrated and betrayed by the system that was supposed to protect the patient.

 

To everyoneÕs surprise, John slowly woke from his comatose state and began to interact with the world around him again. The family felt vindicated in their actions. This experience then formed the basis for the familyÕs mistrust of any further housestaff statements about JohnÕs quality of life or his chances for recovery.

 

Then the issues of resuscitation status and patient competency emerged. When you started working with John, he was Full Code (CPR). He had great difficulty clearing his own secretions and one night suffered from a desaturation episode secondary to mucus plugging. He was revived successfully with aggressive suctioning and supplemental oxygen, but the episode triggered a downturn in his general course. He subsequently again developed pre-renal failure, his mental status deteriorated, and his respiratory status worsened. That night when the issue of his code status was addressed with his family, they declared that they wanted everything done; in fact, they specifically requested that he be intubated. They reiterated their request the next day: they wanted all measures taken if his heart or respiration were to fail, including defibrillation, CPR and intubation.

 

As JohnÕs condition deteriorated, he seemed to change. He had been interacting actively with the staff and looked forward to physical therapy; now, he rapidly lost interest in all activities. He no longer spoke to the nurses or housestaff unless prompted with repeated questions. He simply stared at the ceiling, and when asked how he felt, he only said that he was tired. One afternoon, after a week of what seemed to be progressive deterioration, you went into JohnÕs room with his primary nurse and had a long talk. John had previously shared feelings of depression and hopelessness, but this time he specifically denied feeling depressed. He stated that he was just tired and didnÕt want to live like this anymore. When you asked him directly what he would want done if his heart were to stop, he very clearly said, ÒJust let me go.Ó

 

You then explained that there are a variety of levels of care that can be offered to patients, depending on their own and their familyÕs wishes, and you proceeded to outline these options for him. When asked, he indicated that he would want medication for a headache but that he wouldnÕt want any more blood draws or other tests. When you explained that sometimes those tests can help figure out what is wrong with a patient and help to treat the condition, he wasnÕt as sure. What he very clearly kept repeating however, was that he would not want CPR or intubation if his heart were to stop. He said he had been thinking about this for some time and was sure of his feelings. He had not yet told his family how he felt, but he agreed to talk to them about it at their next visit.

 

When his family came in later that evening, the social worker and primary nurse accompanied them into JohnÕs room. Once again, without any prompting, John stated that he was tired, had had enough, and did not want to live like this anymore. Taken aback, his family told him that he did not know what he was saying. He repeated himself and said ÒJust let me go.Ó The family became very agitated and stated firmly that he was not in his right mind, that they were the ones making the decisions, and that he was to remain a full code.

 

Many people, including you, spent hours talking with his family about this issue. You assured them that the DNR order would not mean that anyone would stop aggressively treating his various medical problems, but they held firm. They just did not believe that he understood what he was saying. They said that while they knew he did not have much to look forward to, they wanted him to live so that they could visit him every day in a nursing home. In addition, they insisted, ÒWe canÕt stop now, not after all this time.Ó

 

Ultimately, because of the discrepancy of JohnÕs stated wishes and those of his family, a psychiatry consult was called to determine his capacity to make these decisions. He confused his age and the year, and though he knew he was in the hospital, he didnÕt know which one. Thus, he was deemed incapable of making these decisions. This was upsetting. Here was a man who was able to state his wishes concerning his medical care very clearly, but was unable to recite the facts required to pass this objective test.

 

Another dilemma that arose was that of the appropriate allocation of scarce resources. Nine months of hospital care, x-rays, CT scans, dialysis, ICU care, and other tests are very expensive. This issue became even more concerning when Utilization Review began putting notes on the chart that JohnÕs Medicare reimbursement for his hospital stay had been fully spent--and that it was time to move him to the nursing home, since from that time on, the hospital was underwriting his care. Now as you end the rotation and transfer JohnÕs care to your partner, the family is still demanding aggressive care for John, he is questioning why you continued to do these things to him with non-verbal communication, and the hospital has lost nearly $100,000 on his care.