Gregg VandeKieft

End-of-life care when the state is the guardian.

David N is a 40-year-old male with a history of congenital hydrocephalus and profound mental retardation. He has no family and has been under the care of the State Department of Human Services. He has been in the hospital a number of times and has chronic respiratory failure and is ventilator dependent. He is currently septic, completely unresponsive (which is chronic), and hypotensive on 2 pressor agents. He has massive stage IV decubiti on his sacrum, buttocks, back, and heels. His attending physician feels his condition is terminal. The State Department of Human Services case worker has informed the attending physician that the department cannot authorize a ‘‘do not resuscitate (DNR)’’ order on any patient who is a ‘‘ward of the state’’ and explains that this is department policy and is intended to prevent the appearance of ‘‘laissez-faire’’ care by the agency. The attending physician feels that putting this patient through a ‘‘code blue’’ would increase his suffering and would be unethical. A Palliative Medicine consult was requested.

Diversion of opioid pain medications at end-of-life.

Mr J is a 67-year-old white male with a history of metastatic pancreatic cancer. His pain has been controlled with extended release oxycodone 40 mg twice a day, and oxycodone immediate release 10 mg every 4 hours as needed. Recently, his functional status declined and his daughter moved in to help care for him (he was previously living alone). The hospice nurses note that the patient’s pain is increased lately, and when they visit, the daughter seems ‘‘out of it’’. The patient’s pill count is low, indicating a shortfall of 10 extended release oxycodones and 20 immediate release tablets over the last 7 days. Mr J states his daughter gives him his medicine, and that his pain has been 6 to 7 on a scale of 1 to 10 for several days. When asked about the missing oxycodone tablets, Mr J becomes very defensive, stating his daughter would never take his medicine. The daughter also denies diversion, though she falls asleep twice during the interview. Mr J declines inpatient hospice to control his symptoms and to monitor his medication use, stating ‘‘you can take care of me here...I just need more medicine.’’ Medical Perspective

The principle of distributive justice.

Erik N is a morbidly obese male with a long history of Pickwickian syndrome. He has right heart failure due to cor pulmonale and is totally bedbound. His wife is an advertising executive and her company has insurance that offers family coverage, but Erik and his wife decided not to purchase coverage for him so that they could afford to send their daughter to private school. Last year, Erik and his wife divorced and he hired sitters to care for him at home. Unfortunately, he exhausted his funds and dismissed his sitters. He was found on the day of admission by a neighbor in a semicomatose state. He was immobile, in bed, without adequate hygiene and was taken by Emergency Medical Services to the nearest hospital. Erik has been stabilized, but it is obvious he cannot care for himself at home. He will require nursing home care that he cannot afford and lives in a state with strict Medicaid requirements; he currently does not qualify for state assistance. Given that Erik voluntarily decided not to purchase coverage for himself when he could have and cannot afford the health care he needs, the question arises: does society have an obligation to care for him? Discuss the concept of distributive justice.

Ethics roundtable. Providing care in an unacceptable environment.

M r Z is a pleasant 48-year-old man who works as an independent ‘‘handyman.’’ He lives alone and states he has little contact with his family. Recently, he was diagnosed with metastatic colorectal cancer and was treated with external beam radiation to a painful hip metastasis. He is currently taking immediate release oxydodone for pain, with good results. Mr Z’s oncologist recommended chemotherapy with continuous infusion 5-fluorouracil, which Mr Z agreed to because he would be able to continue working. When home health arrived to evaluate him for home-based chemotherapy, however, they found that the house was in filthy condition. They reported trash and human feces ‘‘everywhere.’’ There was no sanitary place to keep food inside the house, and there was no electricity or running water. Mr Z was drinking water from the creek. Home health care has refused to provide services for him given his living conditions, unless they will be changed. Mr Z refuses to go to a nursing home and refuses help from Adult Services. He now states that if he had known ‘‘treatment was going to be so much trouble, I never would have agreed to it.’’ If Mr Z responded to the chemotherapy, his prognosis was considered to be approximately 8 months. His oncologist wonders what the next course of action should be.

Surrogates with conflicting interests: who makes the decision?

JH is a 93-year-old male who was admitted with a massive intracerebral bleed. He is currently on mechanical ventilation and is comatose off all sedatives. He has no corneal reflex but has a mild cough and decorticate posturing with noxious stimuli. The patient’s son was at one time the patient’s power of attorney (POA). However, JH revoked this and granted POA to one of his hired caregivers after the son attempted to have him admitted to a nursing home over a year ago. At present, the POA demands a feeding tube and continued aggressive treatment. The son states the patient would never have wanted to have his life artificially prolonged and wants life support terminated and ‘‘comfort measures’’ instituted. The POA claims that the son is acting out of expedience and for his inheritance; the son states the POA is acting out of self-interest as he is being paid by JH as long as JH lives. Neurology feels no return to sapient existence is possible, although the electroencephalography (EEG) was relatively unremarkable. Neurosurgery has nothing to add, and a GI consult for a percutaneous endoscopic gastrostomy tube is pending. The hospitalist feels further aggressive treatment would be futile and that no significant quality of life can be salvaged. An ethics consult is requested.

Placebo: Medicine or Deception?:

GC is an 89-year-old female nursing home resident with carcinoma of the breast. She was first diagnosed at the age of 88 with a fungating lesion of the left breast, and opted for simple mastectomy without chemo or radiation. Metastatic workup was negative. Her performance status had declined and she was admitted to a local hospice program. GC believes her cancer has spread to her bones despite evidence to the contrary. During the admission process, the hospice nurse noted that GC was taking ‘‘Cebocap’’ for pain, which was written by her primary care provider. The nurse was unfamiliar with this medication and looking it up found that it contains ‘‘no active pharmaceuticals’’—that is, it is a placebo. The patient states ‘‘I can’t live without my pain medication,’’ stating that it is quite efficacious for her bone pain. In the hall, the patient’s daughters tell the nurse that they know their mother is taking a placebo and do not want it changed. Nor do they want their mother told that it is a placebo, as she is satisfied with it and depends on it psychologically to function. The hospice nurse is in a quandary; on one hand, the patient is comfortable and satisfied with her current regimen, while on the other hand her autonomy is threatened by what she perceives as the deception inherent in being prescribed a placebo. At the next interdisciplinary meeting, the nurse questions the ethics of placebo use. A vigorous discussion follows.

A ''minor'' decision: right to die or manslaughter?

PT is a 17-year-old male who was admitted to the hospital for a suicide attempt. He was 13 when he returned home from school and discovered his mother had committed suicide. Despite intensive counseling and medical treatment, PT became increasingly despondent. As an adolescent, he experimented with drugs and displayed antisocial behaviors. On the day of admission, his brother, who was 15 at the time, returned home from school to find PT had shot himself in the head with a .22 caliber pistol. He was unconscious and was resuscitated at the scene by EMS. He remained comatose and has been on chronic ventilator management for the last 4 years. His course has been complicated by sacral decubiti, flexion contractures, and frequent pneumonias, requiring inpatient admission. PT resides in a long-term care facility and his father and brother visit daily. After 4 years of soul searching, his father has decided that he ‘‘will never be my son again’’ and approached the administration of the facility about withdrawal of life support. PT’s brother, now 19, is in support of this idea. The facility, however, would not consider the family’s request. In a family meeting, one staff member accused the father of ‘‘wanting to kill his son to get on with his life,’’ and another expressed concern that the father would surreptitiously turn off the ventilator. PT’s father approached a local hospice organization to see if they would accept him in transfer and remove the ventilator. The long-term care facility opposed the transfer; an ethics consult was requested by the attending physician.

Comfort Care Versus Euthanasia

M rs K is a 58-year-old female with a history of morbid obesity and Pickwickian syndrome. Over the last year, she has had severe dyspnea and has struggled to get from bed to bathroom. She stated multiple times over the last year that she ‘‘didn’t want to go on like this’’ and wished she would ‘‘just die.’’ Mrs K was transferred to the emergency department (ED) by emergency medical services (EMS) when her family found her unresponsive in bed. She had a pH of 7.15 and a PCO2 of 90 with an oxygen saturation of 70% on 100% O2 started in the ambulance. She was intubated in the ER at the family’s request. During the night, Mrs K became responsive as her arterial blood gases (ABGs) improved. With mechanical ventilation, her pH was 7.44 with a PCO2 of 35 and an O2 saturation of 100%. Mrs K began gesturing to the endotracheal tube and signaling her family that she wanted it removed. A palliative medicine consultation was requested. The palliative medicine consultant determined that Mrs K understood that extubation would likely be fatal and that she indeed wanted this. The family was in agreement and wanted her ‘‘to be made comfortable.’’ On intubation, Mrs K said ‘‘thank you, and don’t ever do that to me again.’’ She greeted her family and enjoyed a few moments with them. After an hour, she became unresponsive again and was transferred to inpatient hospice. The next day, Mrs K remained unresponsive, with some labored breathing. A morphine patientcontrolled analgesia (PCA) was initially titrated with good results. At 7 PM, the family told her nurse that they were upset that she was ‘‘lingering’’ and that she did not die immediately after extubation. Although the patient was unconscious, the family felt she was ‘‘suffering’’ and wanted her O2 discontinued stating ‘‘we just want to let her go.’’ Once the oxygen was stopped, the patient had increasingly labored respirations. The family demanded that ‘‘something be done’’ and the resident from the primary care service was paged. The resident assessed the situation and wrote ‘‘patient markedly dyspneic, family desperate for symptom relief’’ in the chart and gave 10 mg of intravenous (IV) morphine with some improvement in work of breathing. The resident then gave another 10 mg of IV morphine with significant improvement in work of breathing. Mrs K quietly expired 10 minutes later. The family was thankful to the hospital, physicians, and staff. The next morning, the clinical manager asked whether Mrs K had been euthanized by the resident. An ethics panel was convened.

Decision-Making on a Deadline: Tracheostomy, Nutrition, and Autonomy

JT is an 81-year-old female with metastatic pancreatic cancer who was admitted to the intensive care unit (ICU) after a suicide attempt. Once she was stabilized medically, she reported her cancer pain was so severe and unremitting that she wanted “to end it all.” She stated that if her pain had been well controlled, she “never would have done it.” She was seen by psychiatry and declared to have capacity to make her own decisions. Her pain was managed with oral hydromorphone, and a visual analog pain score was 3 on a scale of 1 to 10. During the interview, she stated clearly that she did not want cardiopulmonary resuscitation (CPR), intubation, or further chemotherapy. She did accept moderately aggressive medical treatment to help stabilize her condition so that she could go home and “enjoy what time I have left.” The patient has a son who lives in another state and was very angry about the idea of limiting treatment and drove down to see her, “to set her straight.” During the next few days, the patient deteriorated significantly and became unresponsive. When the son arrived, he demanded the patient be made “full code” and have full, aggressive treatment. The patient was eventually intubated due to worsening respiratory failure. She self-extubated and was reintubated at the son’s request. The patient is now comatose and has had endotracheal intubation for 14 days. The son refuses to consider tracheostomy and permanent gastrostomy tube for feeding and also refuses to consider palliative extubation and comfort-focused treatment, stating “you’re just trying to get rid of her.” The critical care team feels continued endotracheal intubation will put the patient at risk of tracheal erosion and wants an answer immediately. An ethics consult is requested.

Autonomy and Withdrawal of Treatment in a Patient With Depression

AJ is a 59-year-old male with a history of poorly controlled diabetes mellitus (type 2), cardiovascular disease, multiple strokes, and end-stage renal failure (dialysis dependent). Patient states he was previously very active, but after his stroke he has been cared for in an intermediate care facility. His course has been complicated by multiple decubitus ulcers, immobility, aspiration pneumonia, and urinary tract infections, resulting in multiple hospital admissions. On this admission, AJ was diagnosed with vancomycin-resistant enterococcal sepsis. When transport arrived to take him to dialysis, he refused, stating “I no longer want to live like this.” The attending physician consulted psychiatry who diagnosed major depression and felt patient did not have the capacity to make the decision to withhold treatment. The nephrology team refused to dialyze the patient “against his will.” Palliative medicine was consulted to determine surrogacy and to evaluate capacity. AJ expressed understanding of his situation and the consequences of his action stating “I don’t want to kill myself, but if I stop dialysis I’ll die and that is my wish.” AJ also stated “who wouldn’t be depressed in my situation?” AJ has no identified surrogate, being estranged from his spouse who was reportedly abusive, and lacked other relatives or friends. The attending physician was assigned surrogate and immediately ordered an ethics consult.