CASES

1. CASES FINDING THE KEY

2. HOWARD RUSSELL I[DETERMINING FUTILITY] • Howard Russell is 34 years old and was diagnosed with AIDS when he became symptomatic in 1993. Ordinarily persons with AIDS will live about 21 months after they become symptomatic if they do not respond to the protease inhibitors. Mr. Russell has not responded to the protease inhibitors but has still lived 30 months. However, he is nearing the end. He is in the hospital and suffering from another infection and poor nutrition. He is being given antibiotics which are temporarily controlling the infection and he is being tube fed. • IS MR. RUSSELL TERMINALLY ILL? • IF HE IS TERMINALLY ILL WHAT QUESTIONS SHOULD BE ASKED ABOUT TREATMENTS THAT MIGHT BE CONSIDERED FOR HIM? • HOW WOULD YOU ASSESS MR. RUSSELL’S QUALITY OF LIFE?

3. HOWARD RUSSELL II • The prognosis is that he will not leave the hospital, the tube feedings will have to continue, the antibiotics will be useful for only a limited time, and there is a good chance that he will experience cardiac arrest in a short period of time. • IS THIS PROGNOSIS A GOOD REASON TO STOP ALL TREATMENTS? • SHOULD THE THREATMENTS THAT HAVE BEEN BEGUN CONTINUE SINCE THEY ARE FUTILE? • SHOULD ANY NEW TREATMENTS BE INITIATED?

4. HOWARD RUSSELL III • Upon admission, Mr. Russell agreed to a DNR order but after one week, he requested that the DNR order be reversed and that he be made a full code. There is no question about his decisional capacity. • WOULD RESUSCITATION BE FUTILE FOR HIM? • SHOULD MR. RUSSELL BE ALLOWED TO CHANGE HIS MIND? • WHAT SHOULD BE THE CLINICAL RESPONSE TO THIS CHANGE OF MIND?

5. HOWARD RUSSELL IV • His physician and the medical staff think that a full code is inappropriate because of his failing condition. Their assessment is that, even if he were to survive the code, he would end his few remaining days on a ventilator. They admit that there is some chance that Mr. Russell might regain consciousness after being resuscitated even though he would be on a ventilator. • WHY DOES HIS PHYSICIAN THINK THAT THE FULL CODE IS INAPPROPRIATE? • WOULD CPR COUNT AS A FUTILE TREATMENT? • IF CPR IS FUTILE, WHAT ABOUT THE OTHER TREATMENTS? ARE THEY FUTILE AS WELL? • SHOULD THE PHYSICIAN’S JUDGMENT OVERRIDE MR. RUSSELL’S CHANGE OF MIND?

6. HOWARD RUSSELL V • Mr. Russell insists on resuscitation efforts partly because he wants to see his brother who is coming into town from Montana and partly because he simply does not want to surrender to AIDS. • IS WANTING TO SEE HIS BROTHER SUFFICIENT REASON TO OVERRIDE THE FUTILITY DECISION OF THE PHYSICIANS? • IS WANTING NOT TO SURRENDER TO AIDS SUFFICIENT REASON TO OVERRIDE THE FUTILITY DECISION OF THE PHYSICIANS? • IS THERE A WAY THAT MR. RUSSELL AND HIS PHYSICIANS CAN COME TO SOME NEGOTIATED AGREEMENT? • WHAT DO YOU THINK THE TERMS OF THAT AGREEMENT SHOULD BE?

7. TODD Z. I[INFORMED CONSENT] • Todd Z. is a 75-year-old male who has been diagnosed as having lung cancer with brain metastases. His physician of thirty years, Dr. S., is seriously concerned that, if told of his diagnosis, Todd Z. will go into a deep depression and spend the remainder of his life in that state. • SHOULD DR. S.’S CONCERN ABOUT DEPRESSION INTERFERE WITH THE DYNAMICS OF INFORMED CONSSENT? • WHAT COULD BE DONE TO MITIGATE THE IMPACT OF “DEPRESSION” ON INFORMED CONSENT? • SHOULD DR. S. BE HELPING TODD Z. MAKE DECISIONS ABOUT FUTILE CARE?

8. TODD Z. II • Dr. S. keeps the information from Todd Z. and orders Todd Z.'s wife and three sons not to tell the patient of the diagnosis. He claims that "deep down" Todd Z. would not want to know about his diagnosis. He tells them that he wants to keep the patient in the hospital for a couple of weeks for brain radiation and promises to make up some excuse for the treatment. After the treatment is concluded, the family can take him home to die. • IS IT APPROPRIATE, OR EVEN ACCURATE FOR THE PHYSICIAN TO GUESS WHAT THE PATIENT WOULD WANT? • IS IT APPROPRIATE TO STOP COMMUNICATION BETWEEN THE PATIENT AND HIS FAMILY? • IS TODD Z.’S SELF-DETERMINATION IN JEOPARDY? • WHAT IS THE QUALITY OF THE FIDUCIARY RELATIONSHIP AT THIS POINT?

9. TODD Z. III • Dr. S. promises that he will visit Todd Z. at his home every week and care for him until he dies because he has been very fond of him and lives nearby. Todd Z. becomes increasingly persistent with his questions about his physical condition. By the third week the family breaks down and tells him about the diagnosis. Todd Z. does go into the predictable depression, but it is not as severe as Dr. S. had feared. • IS TODD Z.’S PERSISTENCE AN INDICATION THAT HE WANTS HIS VALUES TO BE INCORPORATED IN ANY DISCUSSION ABOUT HIS CONDITION AND TREATMENT? • COULD THIS PERSISTENCE LEAD TO A DISCUSSION ABOUT THE FUTILITY OF HIS TREATMENTS? • WAS IT APPROPRIATE FOR THE FAMILY TO GO AGAINST THE PHYSICIAN’S DIRECTIVE? • WHAT COULD BE DONE ABOUT TODD Z.’S MENTAL STATE?

10. TODD Z. IV • Dr. S. is angered by the fact that the family has disobeyed his orders. He releases Todd Z. from the hospital and does not keep his promise to visit him at home. He never visits him during the six-month period from Todd Z.'s departure from the hospital to the day of his death. During that six-month period Dr. S. is very uncooperative. When the family contacts him to discuss the medication program, he is very curt with them, and when they ask him about a particular condition that is developing, he insists that they will have to bring Todd Z. to the office or to the hospital. He even refuses to talk with the patient on the telephone. • WHAT IS THE QUALITY OF THE FIDUCIARY RELATIONSHIP NOW? • DOES DR. S.’S ATTITUDE TOWARD INFORMED CONSENT REVEAL A DEEPER PROBLEM IN HIS CHARACTER? • HOW HAS DR. S.’S ATTITUDE TOWARD INFORMED CONSENT, AND HIS PROFESSIONAL ATTITUDE TOWARD TODD Z., INHIBITED MR. Z. FROM MAKING ANY DECISIONS ABOUT THE FUTILITY OF HIS TREATMENT?

11. MR. BARTLING I[VALUES] • William Bartling was 70 years old when he entered Glendale Adventist Hospital in California in 1984. He entered the hospital for treatment of depression. At the time of his admission he was known to be suffering from emphysema and arteriosclerosis. At the time of his admission a routine physical examination revealed a tumor on his lung and a biopsy confirmed that it was malignant. The biopsy needle caused the lung to collapse and the emphysema prevented the lung from reinflating causing chronic respiratory failure. He was placed on a ventilator with a tracheotomy. In addition Mr. Bartling had an abdominal aneurysm. Although each of these conditions could individually be lethal, he was not diagnosed as terminally ill. Attempts to wean him from the ventilator were unsuccessful and he was considered to be ventilator dependent. His physicians admitted that, at best, he could only live for a year if he could be weaned from the ventilator. • IS MR BARTLING TERMINALLY ILL? • WHAT FEATURES OF HIS CONDITION WOULD LEAD YOU TO YOUR CONCLUSION?

12. MR. BARTLING II • Initially Mr. Bartling attempted to remove the ventilator tubes but was unsuccessful. To prevent a successful attempt, he was placed in restraints so that the tubes could remain in place. Both Mr. Bartling and his wife asked the physicians to remove the ventilator but they refused. • SHOULD MR. BARTLING’S ATTEMPT TO REMOVE THE VENTILATOR TUBES BE SEEN AS HIS JUDGMENT ABOUT THE FUTILITY OF HIS TREATMENT AND AN EXERCISE OF HIS RIGHT TO REFUSE TREATMENT? • WAS IT ETHICALLY CORRECT TO PLACE MR. BARTILING IN RESTRAINTS? • WERE THE PHYSICIANS CORRECT IN REFUSING TO REMOVE THE VENTILATOR?

13. MR. BARTLING III • Mr. and Mrs. Bartling then filed a complaint against Glendale Adventist Hospital seeking damages for battery and the violation of Mr. Bartling's constitutional rights both state and federal. As a part of the complaint, there was attached a living will executed by Mr. Bartling and his appointment of Mrs. Bartling as his attorney-in-fact in a Durable Power of Attorney for Healthcare. In the documents Mr. Bartling expressed a clear understanding of his healthcare condition, the distress he was in as a result of the continued ventilator support, the consequences (which could result in death) of the removal of the ventilator, and his unswerving desire to have the ventilator disconnected. • ARE MR. BARTLING’S VALUES CLEAR ABOUT THE FUTILITY OF HIS TREATMENT? • DID THE HOSPITAL COMMIT BATTERY AGAINST MR. BARTLING? • WHAT AUTHORITY SHOULD ATTACH TO THE ADVANCE DIRECTIVE IN THIS CASE? • DOES THE ADVANCE DIRECTIVE SEEM CONVINCING?

14. MR. BARTLING IV • His wife and daughter added documents which released the hospital and his physicians from all civil liability for whatever consequences might result from following his wishes. The hospital and his physicians remained steadfast in their refusal to disconnect the ventilator both because he was not considered terminally ill and because, so they contended, the religious traditions of the hospital required that life be preserved as long as the patient had cognition, even with such a poor quality and prognosis. • HAVE HIS WIFE AND DAUGHTER PROTECTED THE HOSPITAL? • WHAT DO YOU MAKE OF THE PHYSICIAN’S REFUSAL TO CONSIDER MR. BARTLING TERMINALLY ILL? • SHOULD THE RELIGIOUS COMMITMENTS (VALUES) OF THE HOSPITAL DICTATE THE PATIENT’S CARE? • HOW SHOULD QUALITY OF LIFE CONSIDERATIONS ENTER INTO THESE CLINICAL DECISIONS?

15. MR. BARTLING V • The situation was complicated by the apparent vacillation of Mr.. Bartling in his decisions. He said that he did not want to die but neither did he want to live on a ventilator. However, at times he seemed to be reconciled to his impending death. On the infrequent occasions when the tubes became accidentally disconnected he seemed to gesture to the nurses to reconnect them. Finally, there were reports by some of the physicians that Mr. Bartling had said that he did not want the ventilator disconnected. • WHAT DO YOU MAKE OF HIS GESTURES TO RECONNECT THE VENTILATOR? • SHOULD MR. BARTLING BE CONSIDERED TO BE LACKING DECISIONAL CAPACITY? • WHAT DO YOU MAKE OF THE APPARENT RECONCILIATION WITH HIS DEATH? • HOW WOULD YOU HELP HIM CLARIFY HIS VALUES SO THEY ARE CONSISTENT REGARDING THE FUTILITY OF HIS TREATMENT?

16. MR. THOMAS I[POLICY] • Mr. Thomas is a 75 year-old patient who is suffering from end-stage COPD (emphysema). He has made frequent visits to the hospital in the past two years but after 7-10 days on the ventilator he has recovered enough to return home where he is tethered to an oxygen tank and can leave his home only with great difficulty. • WHAT IS THE FIRST THING THAT SHOULD BE DISCUSSED WITH MR. THOMAS TO PREPARE HIM FOR HIS FUTURE? • SHOULD THE PHYSICIAN BE TALKING WITH MR. THOMAS ABOUT FUTILE CARE IN THE FUTURE?

17. MR. THOMAS II • He has recently been diagnosed with lung cancer and the prognosis is that he has less than six months to live. He has elected to undergo chemotherapy for his cancer against the advice of his physician who has said that the chemotherapy will not really retard the growth of the cancer significantly and will only make him more miserable because of the side-effects of the therapy. • SHOULD THE PHYSICIAN BE BLUNT ABOUT THE FUTILITY OF THE CHEMOTHERAPY? • HOW SHOULD MR. THOMAS’ VALUE LIFE BE EXPLORED TO DETERMINE WHY HE WANTS TO GO AGAINST HIS DOCTOR’S ADVICE? • SHOULD THE PHYSICAN TAKE INTO ACCOUNT PERSONALLY-DETERMINED FUTILITY TO GIVE MR. THOMAS THE BEST CARE?

18. MR. THOMAS III • As a result of the combination of the two diseases, Mr. Thomas' lung function has deteriorated rapidly and he has been admitted to the hospital where the pulmonologist says that he will never be weaned from the ventilator. His oncologist, his pulmonologist, his internist, and his intensivist all agree that no therapy will improve his condition and that he is effectively dying although he may not die soon. It may be a matter of weeks or a month or so at the most. He tells his physicians that he wants everything done to prolong his life and his family concurs with his decision. He said “I’ve paid taxes all my life and I’m gonna get my money’s worth out of Medicare.” • IS VENTILATOR SUPPORT FUTILE? • SHOULD THE PHYSICIANS REFUSE ANY ADDITIONAL INTERVENTIONS? • IS MR. THOMAS’ ATTITUDE ENOUGH TO JUSTIFY FUTILE CARE?

19. MR. THOMAS IV • He has an advance directive, which reinforces his wishes and his daughter who is his healthcare proxy agrees to follow his wishes if he loses decisional capacity. The physicians reluctantly agree to follow Mr. Thomas' wishes in part and they keep him on the ventilator and continue the chemotherapy. However, they agree among themselves that they will not offer him CPR nor will they perform it if he gets into cardiac difficulty. Nor will they use antibiotics if he develops an infection. Both orders were written in the chart without the knowledge of either the patient or the family. • CAN A PATIENT DEMAND FUTILE CARE IN AN ADVANCE DIRECTIVE? • CAN THE PHYSICIAN MAKE A UNILATERAL DECISION NOT TO PROVIDE FURTHER CARE? • COULD THE PHYSICIANS KEEP HIM ON THE VENTILATOR AND STOP THE CHEMOTHERAPY? • HOW COULD A HOSPITAL POLICY HELP IN THIS CASE?

20. MR. CARLSON I[ADVANCE DIRECTIVES] • Mr. Carlson is 73 years old and has been diagnosed with lymphoma. He received one course of chemotherapy but was told that even with another course of chemotherapy the best he could hope for was another 6 months to live. • IS MR. CARLSON TERMINALLY ILL? • WHAT MATTERS SHOULD BE CONSIDERED IN THE DECISION ABOUT ANOTHER COURSE OF CHEMOTHERAPY? • WHAT SHOULD THE DOCTOR BE TALKING ABOUT WITH HIM AT THIS POINT? • WOULD YOU CONSIDER ANOTHER COURSE OF CHEMOTHERAPY FUTILE?

21. MR. CARLSON II • He had been living alone in Reno but decided to move to Cleveland to live out his days with his niece who is his only relative. • WHAT DOES THIS MOVE TELL YOU ABOUT MR. CARLSON’S DEATHSTYLE? • WHAT SHOULD MR. CARLSON AND HIS NIECE BE TALKING ABOUT AT THIS TIME?

22. MR. CARLSON III • After settling in his new home he began to suffer from congestive heart failure and went to Dr. Morrow, a local oncologist for help. • HOW SHOULD DR. MORROW APPROACH HIS CLINICAL ENCOUNTER WITH MR. CARLSON? • WHAT SHOULD DR. MORROW ATTEMPT TO LEARN ABOUT MR. CARLSON? • WHAT SHOULD MR. CARLSON ATTEMPT TO LEARN ABOUT DR. MORROW?

23. MR. CARLSON IV • Dr. Morrow ordered hospitalization and Mr. Carlson agreed but insisted that he be made DNR upon admission. His niece agreed with his request and presented Dr. Morrow with a copy of her uncle's living will and durable power of attorney for healthcare (appointing her as the attorney-in-fact) which he had signed in Nevada. • IS IT APPROPRIATE FOR MR. CARLSON TO “INSIST” ON BEING DNR? • WHAT SHOULD BE DR. MORROW’S REACTION TO MR. CARLSON’S DECISION? • SHOULD DR. MORROW CONSIDER CPR FUTILE? • HOW SHOULD THE DNR COMFORT CARE LAW IN OHIO PLAY OUT IN THIS SITUATION? • IS A NEVADA ADVANCE DIRECTIVE VALID IN OHIO?

24. MR. CARLSON V • However, Dr. Morrow talked Mr. Carlson into being a full code "for a while" so his situation could be assessed. • IS IT APPROPRIATE FOR DR. MORROW TO PERSUADE MR. CARLSON TO BE A FULL CODE? • SHOULD DR. MORROW BE MORE SPECIFIC THAN “FOR A WHILE?” • IS DR. MORROW TAKING ADVANTAGE OF MR. CARLSON’S VULNERABILITY? • IS AN ASSESSMENT NECESSARY? • DOES MR. CARLSON HAVE TO BE A FULL CODE FOR THE ASSESSMENT TO BE DONE?

25. MR. CARLSON VI • After three days Mr. Carlson arrested and he was resuscitated and placed on a ventilator. His niece requested again that he be made DNR. • WHAT SHOULD DR. MORROW DO NOW? • WHAT ETHICAL PRINCIPLE SHOULD DR. MORROW BE FOLLOWING IN ADDRESSING MR. CARLSON’S SITUATION? • WHAT ABOUT THE OHIO DNR COMFORT CARE LAW NOW? • IS MR. CARLSON’S CARE NOW FUTILE? • WHAT IS THE FORCE OF THE ADVANCE DIRECTIVE AT THIS POINT? • WHAT AUTHORITY DOES THE NIECE HAVE?

26. MR. CARLSON VII • A neurological consult revealed that his EEG was so bad that, even if he could be weaned from the ventilator, his mental status would be highly impaired. • IS QUALITY OF LIFE AN ISSUE HERE? • DID MR. CARLSON’S VALUE DECISIONS COVER THIS SORT OF SITUATION? • WHAT KIND OF FUTILITY DECISION SHOULD BE MADE NOW? • HOW COULD MR. CARLSON’S ADVANCE DIRECTIVE HAVE HELPED IN THIS SITUATION?

27. MR. CARLSON VIII • Dr. Morrow still refused to make him DNR and the next day when his kidneys suddenly ceased functioning Mr. Carlson was sent for dialysis without the consent of his niece. • SHOULD MR. CARLSON HAVE BEEN SENT FOR DIALYSIS? • SHOULD DR. MORROW HAVE SECURED THE CONSENT OF MR. CARLSON’S NIECE BEFORE SENDING HIM TO DIALYSIS? • IS MR. CARLSON RECEIVING FUTILE TREATMENT NOW?

28. MR. CARLSON IX • While receiving dialysis his blood pressure bottomed out and he was given vasopressors to restore it. Another neurological consult revealed an even more compromised EEG which indicated that he had a 93% chance of being vegetative and a 7% chance of severe mental impairment with 0% chance of returning to his previous level of functioning. • WHAT SHOULD DR. MORROW DO NOW? • WHAT SHOULD MR. CARLSON’S NIECE DO NOW? • WHAT IS THE FORCE OF THE ADVANCE DIRECTIVE AT THIS POINT? • DO YOU THINK DR. MORROW WOULD/SHOULD ADMIT TO THE FUTILITY OF TREATMENT NOW?

29. BOBBY C. I[ECONOMIC CONSIDERATIONS] • Bobby C. is now six months old. He was born prematurely with a birth weight of 800 grams and had multiple problems from the beginning. • HOW SHOULD WE THINK ABOUT THE CHANCES OF SURVIVAL FOR LOW BIRTH-WEIGHT INFANTS? • IS THERE A LOW BIRTH-WEIGHT THRESHOLD? • IS IT EVER APPROPRIATE TO TALK ABOUT FUTILE CARE FOR INFANTS?

30. BOBBY C. II • Bobby developed hyaline membrane disease due to his underdeveloped lungs and the need for a respirator. He also developed rickets. A CAT scan revealed some calcium deposits in the brain that might or might not compromise his mental functions. He is also microcephalic. Within the first month, Bobby developed thrombocytopenia (low platelet count) for which he was given transfusions. He now suffers from a depression of his immunological system, indicating HIV/AIDS related to the transfusions. He shows little interest in eating, and all attempts to bottle-feed him have failed after a couple of days. • IS BOBBY SUFFERING FROM MULTIPLE SYSTEM FAILURE? • CAN ANY OF THESE PROBLEMS BE REVERSED? • IS BOBBY IN “TERMINAL” DANGER? • SHOULD THE PHYSICIANS BE HAVING A DISCUSSION WITH HIS PARENTS ABOUT FUTILE TREATMENTS?

31. BOBBY C. III • His healthcare costs are being supported by Medicaid, and they are estimated to be in the neighborhood of $850,000 for his six months of hospitalization. • IS THIS A REASONABLE AMOUNT TO PAY FOR 6 MONTHS OF LIFE WITH THIS OUTCOME? • DOES IT LOOK LIKE THE HIGH COST OF HIS CARE WILL CONTINUE? • SHOULD RESOURCE ALLOCATION BE CONSIDERED IN THIS CASE? • HOW SHOULD RESOURCE ALLOCATION BE WEIGHED AGAINST POSSIBLE OUTCOMES OF FUTILE CARE?

32. BOBBY C. IV • Now the healthcare staff, the attending physician, and his parents are considering the possibility of a bone marrow transplant to deal with the thrombocytopenia and the immunosuppression. The chances of success in an infant this small are minimal, and the procedure is largely experimental in infants having this condition. • IS THE BONE MARROW TRANSPLANT FUTILE CARE? • IF THE TRANSPLANT WERE SUCCESSFUL , HOW WOULD HIS OTHER PROBLEMS BE AFFECTED? • ARE THERE LIMITS TO AGGRESSIVE INTERVENTIONS WHEN CARING FOR NEWBORNS? • IS THERE A LIMIT TO THE AMOUNT OF MONEY THAT SHOULD BE SPENT ON ANYONE WHEN ALL INDICATIONS ARE THAT THE CARE IS FUTILE?

33. BOBBY C. V • If the transplant is successful, it will only alleviate one of his many problems. • WHAT DO YOU THINK OF BOBBY’S QUALITY OF LIFE? • COMPROMISED MENTAL FUNCTION • CALCIUM DEPOSITS • MICROCEPHALY • BONE DEFORMITIES • FAILURE TO THRIVE • HIV/AIDS

34. BOBBY C. VI • The parents want to authorize the transplant because they think his condition is a punishment from God because they were seriously considering aborting Bobby early in Ms. C.'s pregnancy. • DO THE PARENTS HAVE ENOUGH INFORMATION IN THIS CASE? • WHAT ROLE SHOULD MEDICAL UNCERTAINTIES AND PROBABLITIES PLAY IN THE CONVERSATIONS WITH THE PARENTS ABOUT FUTILE CARE? • ARE THE PARENTS’ BELIEFS ABOUT “PUNISHMENT” EXERCISING A COERCIVE INFLUENCE ON THEIR CONSENT? • SHOULD THE PARENTS’ BELIEFS BE HONORED EVEN THOUGH THE TREATMENT MIGHT BE FUTILE?