Below are 3 different case studies of end of life care. Read through each case study and answer the discussion questions at the end of each case.

Unit 5 Assignment:Ethical Issues in Palliative Care Case Studies

Instructions:The case studies presented here are meant for you to think about end of life care issues.Read through the case studies and answer the discussion questions after each study.Feel free to do some research before answering the questions.

Case Study #1

Joleen: No Guardian

This case, which draws on committee members’ experiences in caring for older people with varying problems, illustrates the difficulties that clinicians face in making decisions for patients who are not fully competent mentally and who have no family surrogate to act on their behalf.

Joleen Wright, an 87-year-old woman living in a nursing home, had been pleasantly convivial and moderately demented for some time.No family or friends were known.It was very hard to discern her preferences, as she “lived in the present” and did not trouble herself about future possibilities.She had chronic hypertension and hearing and motion deficits.Gradually, over a few weeks, she started doing “poorly,” walking less, eating less, and seeming more distant.Over the next two weeks, a comprehensive evaluation in her nursing home setting turned up very little.Blood tests, physical exams, and chest x-rays were all normal, but she then became short of breath and was hospitalized.By the time she arrived at the emergency room, her blood pressure had declined to dangerous levels.She had mild problems with oxygenation, probably due to pulmonary edema, and was started on monitoring and careful fluid balance.Within 24 hours, she had multiple interventions (e.g., IV, cardiac monitor, urine catheter) for monitoring and treatment and was restrained in bed to keep the connections in place.Her skin was breaking down on her shoulder blades.She was able to indicate “yes” or “no” to questions about her comfort but showed little insight or attention.No definite reversible diagnoses surfaced despite appropriate work-up.Her condition worsened, and she faced the need for mechanical ventilation.The care team anguished over whether to continue intrusive care in the intensive care unit in order to establish a clear diagnosis or to shift toward a primarily palliative approach.Her condition continued to deteriorate, and she became minimally responsive.After a team meeting, the care team decided to institute hospice-type care and not to seek a court’s involvement in getting a guardian.Joleen Wright died comfortably 36 hours later.Because no consent to autopsy could be obtained, the diagnosis remained a mystery.

Source:

Field & Cassel. (1997).Approaching death: Improving care at the end-of-life (pp. 53-54) Washington, D.C.:

National Academy Press.

Discussion Questions:

1.Should age be a deciding factor in the provision of care?Why or why not?

2.Should we allow people to die from aging without knowledge of a primary terminal disease process?

• What care would you want if this were you?How do your personal values influence your preferences?
• What role could a nurse play in addressing the ethical issues in this case?

Case Study #2

Mrs. C.:No Advance Directive

Mrs. C., an 85-year-old woman with severe emphysema, is found unresponsive by the nursing staff. Since she has no living will or advance directive, an ambulance is called. Emergency medical personnel perform endotracheal intubation and resuscitate her successfully.She then is taken to the local hospital for treatment of pneumonia and respiratory failure.After treatment for her medical conditions, she cannot be weaned from the respirator.The patient is able to communicate her wishes by using head signals and writing notes.After several weeks of treatment, she asks that the respirator be discontinued and she be allowed to die.Mrs. C. asserts emphatically that she would not have wanted to be resuscitated in the first place, although she never executed an advanced directive or discussed these specific wishes with anyone.

Discussion Questions:

• Is the patient’s decision a rational one?
• What is the difference between withholding and withdrawing life-sustaining treatment?
• In view of the fact that a potent sedative such as morphine may produce respiratory depression, should this be given prior to discontinuing the respirator?Would this constitute active euthanasia?
• Would the situation be different if Mrs. C. had a living will?
• What role could the nurse play in addressing the ethical issues in this case?

Case Study #3

Horace Bowman: Daughter Regrets Decision

The following case illustrates problems that patients and families can encounter with high-technology intensive care that is aimed solely at life-prolonging measure and not organized to consider the whole patient, the benefit/burden ratio of treatment, and the needs of family members for communication attentive to their concerns.

Horace Bowman was a 74-year-old man whose wife had died the year before.He had problems with angina and peripheral vascular disease but continued to smoke about a pack of cigarettes a day.He had not completed any advance directives and had been uncomfortable discussing possible future ill health.He collapsed in the street after suffering a massive heart attack and was rushed to a major hospital center.His daughter lived across the country and flew in to be with her father.She found him unable to communicate because he was intubated and his consciousness fluctuated.When he was alert, he appeared to be in pain and was very agitated.Mr. Bowman’s daughter wanted to discuss her father’s chances of recovery and whether intensive care was helping.She found several physicians involved in her father’s care, none of whom were willing to talk with her for more than a couple of minutes.On the fifth hospital day, the cardiac surgeon presented her with consent forms for an emergency revascularization procedure.She asked what the chances were that her father would survive and recover in any meaningful way.Rather than answer these questions, the surgeon merely noted that surgery was the “only hope.”The daughter felt pressured to sign the forms.As Mr. Bowman was being prepared for emergency surgery, he went into cardiac arrest and, despite resuscitation, died.The daughter felt that the intensive care environment deprived her of the opportunity to spend time with her father. The treatment also made informed decision-making difficult if not impossible, and subjected her father to intrusive tests and interventions that would make her memory of his dying a continuing source of guilt and regret.She was, however, too drained of energy to complain and felt no one would respond anyway.

Source:

Field & Cassel. (1997).Approaching death: Improving care at the end-of-life (pp. 54-55). Washington D.C.:

National Academy Press,

Discussion Questions:

• Was Mr. Bowman’s respect for autonomy violated?
• If this were your family member, how would you want it to be different?
• What could a nurse do to affect system changes to prevent such situations?