CASE 1:

    Mr. Smith, a 77 year old male with end-stage COPD, was brought to the emergency room by his wife with shortness of breath. The patient’s wife reported that her husband had a fever, anorexia, vomiting and altered mental status for 3 days. The patient deteriorated while in the ER and was intubated and transferred to the ICU. His admission diagnosis was sepsis and pneumonia. The patient required vasopressor support due to profound hypotension. Tube feedings (via keofeed tube) were started. His co-morbidities included chronic renal failure, end-stage COPD, diabetes, and cardiomyopathy with an ejection fraction of 20%. His functional status for the 6 months prior to admission was housebound (bed to wheelchair). The family had recently remodeled the house to accommodate the patient’s disabilities and declining functional status.

    Mr. Smith was married (35 years) to his second wife who was of Asian decent. He had two adult children from his first marriage. He was very close to his oldest son who lived a few blocks from the couple. The patient had no specific religious beliefs nor did the family. Mr. Smith allegedly had an advance directive, but his wife would not provide a copy to the hospital. The patient’s insurance was Medicare.

    Mr. Smith had a labile course two weeks into his ICU admission. He was extubated and reintubated twice. The surgical option of tracheostomy was explained to him and his family. The patient and family agreed to proceed with a trach with hopes it would lead to weaning from the ventilator. However, he went into complete renal failure at week three of his admission, and required dialysis 3 times a week. He went on to spend 66 days in the ICU with no improvement. Despite the above complications, his mental status for the most part stayed intact. The family was very attentive, typically spending all day at the hospital.

    The physicians (three) approached the issue of resuscitation several times. The wife and son did not want this discussed with the patient. The attending physician met privately with wife and son and explained the patient’s poor prognosis with little to no chance of ever being able to survive off the ventilator. In addition, the family was told that the patient would be dependent on hemodialysis. The same conversation took place with the patient with 3 healthcare staff members in attendance. The patient verbalized that he understood what the physicians were telling him. He said, “I don’t want to live on machines, but I will tell you when I don’t want to live like this anymore.” The patient was eventually transferred to step-down special care unit on a ventilator and continued hemodialysis. After two weeks on the step-down unit, it was felt that the patient was stable enough to transfer to a long term ventilator facility. There were no facilities in this area that supported ventilator/hemodialysis-dependent patients. Options of transfer out of state or home care were discussed with the family. After 2 more weeks (96 days after admission), the patient was accepted to an out of state facility. The patient, wife and son understood and agreed with transfer out of state.

    The day before scheduled discharge, however, the patient requested to speak to the primary MD. He told the doctor that he wanted to be removed from the ventilator and allowed to die. In addition, he requested that his family not be contacted because: “they won’t listen to me; “they will keep me this way.” He wanted the ventilator removed “now”! The physician explained that without the ventilator the patient would die within hours. The wife arrived at the bedside expecting her regular day at the hospital. She was unaware of her husband’s request. The patient again told the physician and his wife that he wanted to be removed from the ventilator and he did not want his son notified under any circumstances. The physician was suspicious of the patient’s timing of his decision (a day before transfer to a long term ventilator facility out of state). He wanted to call the son and discuss his father’s request. “He can reason with his father.” The physician ordered a psychiatric consult to assess the patient’s mental status. He was fearful of legal liability for himself and the hospital and he called for a bioethics committee meeting. Assume you are on the bioethics committee and are asked to advise in this case.

CME QUESTIONS (true or false):
1. Removal of the ventilator in this patient is euthanasia and is illegal. True   False
2. As a member of the bioethics committee, you should advise the physician he must contact the patient’s son.  The patient’s decision to come off the ventilator indicates he no longer has decisional capacity and his family must now make the decision.    True   False

CASE 2:

    Mrs. Jones, age 74, is brought to the ER by a neighbor. Her left foot is gangrenous. She has lived alone for the last 12 years and is known by her neighbors and her doctor to be intelligent and independent. Her mental abilities are relatively intact, but she is becoming forgetful and sometimes is confused. On the last two visits to her doctor, she called him the name of her former physician who is now dead. On being told that the best medical option for her problem was amputation, she adamantly refused and insisted she was aware of the consequences and accepted them. She calmly told her doctor (whom she called by the wrong name again) that she wanted to be “buried whole.” He considered whether to seek judicial authority to treat. What do you think?

CME QUESTIONS (true or false)
3. Mrs. Jones has the legal right to refuse amputation, even though failing to do so may cause her death. True False
4. The fact that Mrs. Jones is confusing her doctor with her previous doctor suggests she does not have decisional capacity.  The physician should seek judicial authority to treat and amputate her leg.  True   False

CASE 3:

    Mrs. Smith is an 82 year old widow who resided in a long term care facility. Prior to her long term care placement, the patient lived with her oldest daughter. The daughter became unable to care for her mother’s progressive needs and sought long-term placement for her mother in a Skilled Nursing Facility. Mrs. Smith had an advance directive and a designated healthcare surrogate (her oldest daughter). The document was completed 5 years prior to placement in the SNF and was drafted in the state of Michigan. The patient’s co-morbidities included progressive supra-nuclear palsy (PSP), congestive heart failure, malnutrition, and general debility.

    The patent’s Advance Directive stated that she did not want a feeding tube when she became unable to eat. But ten months into her nursing home stay Mrs. Smith was having difficulty swallowing and began to lose weight as her PSP progressed. A feeding tube (PEG) was placed to provide artificial feedings. Six months after the feeding tube was placed, the patient’s condition continued to decline. She was completely bed bound with contracted extremities and unable to communicate. She did not respond to any commands. She was incontinent of stool and urine. The turning point for the family to explore the concept of removing the feeding tube came when the mother began to uncontrollably bite down on her bottom lip. After a few months of biting, the lip tissue eroded and infections became frequent and difficult to treat. Oral care became very difficult. An oral surgeon was called and he recommended transferring the patient to the hospital and removing all of her teeth.

    Five of the patient’s six children wanted to remove the feeding tube and allow their mother to die a natural death. One younger daughter was adamant that removal of the tube was “murder”. She had a strong Catholic faith. She provided her brothers and sisters information from a Catholic website that stated “removing a feeding tube is wrong and an act of euthanasia.” The patient and other siblings were also Catholic.

    In addition, with her very assertive, almost aggressive manner the opposing daughter explained to her brothers and sisters the “horrible death” their mother would suffer from starvation. The family was torn over what to do. They begin to fight among themselves. The opposing daughter refused to consent to discontinuation of the artificial feeding. The long-term care facility wanted a written agreement by all parties if the feedings were to be removed as they feared a lawsuit from the opposing daughter. The family continued to be in discord for another month. The family and the long term care facility finally requested a meeting with the patient’s primary physician.

CME QUESTIONS:
5. Placement of this patient’s feeding tube violated her Advance Directive.  However, once placed, removal of the patient’s feeding tube and, thus, allowing the patient to dehydrate or starve to death is contrary to medical ethics.  True   False
6. A decision to remove the feeding tube must be supported by all of the patient’s children; doing so without consent from all constitutes significant medical liability and grounds for suit.  True   False
7. There is no data that feeding tubes provide patient comfort or significantly prolong life in patients with end-stage disease. True False

CASE 4:

    Mrs. Franks is a 63 year old former heavy smoker with COPD and known coronary artery disease, remote MI and angioplasty, and a previous stroke from which she had made a recovery to a good quality of life. She lived with and cared for her disabled husband. She had experienced more dyspnea than usual for 2 weeks before she presented to the emergency department with respiratory failure requiring intubation and ventilatory support. She was severely hypotensive on admission and required IV pressors and fluids to stabilize her blood pressure. She did not have evidence of pulmonary embolism, overt heart failure or pneumonia. Cardiac enzymes were slightly elevated; EKG was non-specific. Echocardiography demonstrated poor left ventricular function, ejection fraction 30%, with an extremely thin interventricular aneurysm bulging well into the right ventricle with an associated tiny ventricular septal defect and apical akinesis, consistent with extensive anteroseptal and apical infarction, indeterminate age. There was a moderate sized pericardial effusion with a mass-like thickening over the visceral pericardium and evidence of early cardiac tamponade. She was arousable and denied chest pain on the ventilator. The cardiologist suspected she had extensive coronary artery disease and that any possibility of significant longevity would require transfer to a major medical center for consideration of high risk myocardial reduction surgery and septal aneurysm and VSD repair or more likely cardiac transplantation. He felt there was a significant possibility that COPD was too severe to consider cardiac surgery. She appeared to have significant and, as yet, not fully defined comorbid illnesses and lacked decisional capacity. Blood pressure improved, so pericardiocentesis was not performed and cardiac cath was delayed to await further evaluation of pulmonary status.

    After 5 days, Mrs. Franks was weaned off the ventilator. She was able to talk but she was disoriented and confused. Breathing was very labored and after 12 hours she failed her trial off the ventilator and required reintubation and mechanical ventilation. A CT scan of her chest demonstrated lung cancer with enlargement of multiple mediastinal lymph nodes and involvement of both lungs, which was confirmed by bronchoscopy, which showed several endobronchial mass lesions. Biopsy was obtained but results were pending, with suspected small cell tumor or, less likely, lymphoma.

    The cardiologist wrote a lengthy progress note indicating that, based on new findings of lung cancer, the patient was no longer a candidate for cardiac surgery, prognosis was extremely poor, and he suggested a “no code” status, palliative care team consultation, and avoidance of any further invasive procedures. The pulmonologist stated he was waiting on the biopsy for a tissue diagnosis and canceled the palliative care consultation, advising the cardiologist he would counsel with the family when he was sure of the diagnosis. The following day, repeat bronchoscopy was performed to clear secretions and oncology was consulted. The pulmonologist and the oncologist met with the family and the oncologist told the family that the prognosis was poor and that in this type of cancer chest irradiation and chemotherapy might offer a “10% chance of response” if there was no metastatic disease. A bone scan and brain CT scan were ordered.

    The husband was ill at home and was unavailable for discussion. The patient had a clearly written living will stating that if she developed an incurable condition, she did not want life-sustaining treatment and the daughter said she felt her mother would not want “to go on like this” or have her cancer treated. The patient’s brother, who was from out of town, came into conflict with the daughter and demanded that “everything be done.” The pulmonologist agreed that the prognosis was poor but stated that the family had the right to decide about accepting treatment for cancer.

CME QUESTIONS:
8. The patient’ illness is severe, but no single medical problem is untreatable; thus, the situation is not medically futile.  True   False
9. The patient’s condition is incurable and her Advance Directive should come into effect at this stage in her patient’s illness.  The physicians should honor the patient’s Advance Directive, not the request of the son to proceed with aggressive cancer treatment.  True   False
10. The cardiologist should counsel the family regarding the seriousness of the patient’s heart disease, but should not discuss the cancer, leaving that to the pulmonologist and oncologist. True False
 

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