Brother’s Decision

A developmentally delayed man is in need of a kidney transplant. The patient's brother is his guardian, but is not a suitable donor. There is a third brother, though, who may be a suitable donor. The catch is that this brother is also developmentally delayed, and shares the same guardian (the middle brother) as the renal patient. Can the third brother donate a kidney, based on the guardian-brother's consent?

Wife Overrides Husband

A man suffers cardiac arrest and dies in the hospital. His daughter has been on dialysis for a while, but the man refused to give his kidney. He did not sign an organ donation card. His wife wants the man’s kidney given to his daughter. Should the hospital honor the wife’s request?

Patient Wants to Determine Who Gets His Organs

A man comes to the hospital after a motorcycle accident and dies in the ICU. The man’s advance directive indicates that he has agreed to donate organs only under the condition that they “benefit someone who is also Jewish.” Should the organization that allocates organs agree to the request?

Organ Sale

The sale of organs is currently illegal, but a philanthropist offers an interesting way to address the organ shortage. He offers to pay family members of people who are brain dead but did not sign organ donation cards $10,000 to agree to donate the organs of the deceased. Is this an unethical offer? Should the laws be changed to allow payment for organs from live donors, such as kidneys?

Kidney Donor Rules: Moving down the list

Currently, donor kidneys are allocated based on a formula that takes into account four factors: 1) degree of match, with a perfect match giving the patient absolute priority to the kidney, 2) length of time on the waiting list, 3) priority to children, and 4) priority to those who themselves donated a kidney during their lifetime. This formula is under review because it is perceived to have numerous weaknesses. You are on the committee reviewing the rules (called the OPTN/UNOS Kidney Transplantation Committee). What are some possible factors that you might add to the distribution formula? For instance, would you add any of the following to move people down the list?:

• Alcoholism
• Obesity
• Dangerous activity
• Crime

Kidney Donor Rules: Advancing up the list

Currently, donor kidneys are allocated based on a formula that takes into account four factors: 1) degree of match, with a perfect match giving the patient absolute priority to the kidney, 2) length of time on the waiting list, 3) priority to children, and 4) priority to those who themselves donated a kidney during their lifetime. This formula is under review because it is perceived to have numerous weaknesses. You are on the committee reviewing the rules (called the OPTN/UNOS Kidney Transplantation Committee). What are some possible factors that you might add to the distribution formula? For instance, would you add any of the following to advance people on the list?:

• Nearness to death
• Others depend on the recipient
• Contribution to society
• Past service to society

Feeding Tube

A 58 year old man develops multi infarct dementia, and is placed in a nursing home. He is alert, responsive, and can walk with a cane, though he has short term memory loss and believes himself to be in his brother's home. Nevertheless, he seems quite happy where he is.

After 2 years in the home, he has a stroke, and upon waking is unable to speak, though he, can fix on objects. He is paralyzed on the left side of his body, and needs a feeding tube for nutrition. After a few weeks in the hospital, he has shown some improvement, but it is not known whether, or to what extent, he will recover his faculties.

The patient signed a Durable Power of Attorney prior to developing dementia which.
states that he does not want to be kept alive by artificial means, including a feeding tube, if 1) he is terminally ill; or 2) he is permanently unconscious; or 3) the burdens of treatment exceed its benefit. He also told his family at that time that he does not want to live out his life in a nursing home. The DPA/HC names his son as his agent, but the son is uncomfortable asking for limitation of treatment. What should the physicians do?

Infant

A baby is born with a severe genetic defect that results in major brain damage, including deafness and blindness. Moreover, there is little chance of cognitive growth, and no chance of survival past two or three years of age. The infant responds to pain, but is not in pain. The parents want full treatment on the hope of a miracle. Treatment will cause the infant's pain, and can only extend its life for a few months. Must the care team follow the parents’ wishes?

Problem Caused by Hospital

A 68 year old woman was admitted to the hospital after coughing up blood. Her health has been declining in recent years and she made it clear on admittance that while should would accept treatment, she does not want any surgery to keep her alive, and asked for DNR and DNI orders.

The care team decided to do an upper GI scope. They found some abrasions on her esophagus that was causing minor bleeding. Believing that a larger problem may be further down, they went all the way to her small intestine. Unfortunately, the scope perforated her intestine, causing more bleeding. The esophagus problem could probably be treated without surgery, but the intestine problem requires surgery. The woman is now falling in and out of consciousness, and is no longer competent. Should the team do the surgery to fix the intestine?

Pacemaker

A 57 year old man developed heart disease 5 years ago and was given a pacemaker. He was doing well until a year ago when he began getting shortness of breath and suffered renal failure. Two weeks ago he was admitted to the emergency room after an apparent heart attack, where he fell into unconsciousness after resuscitation. It was discovered that he has bloody fluid around his heart. The care team believes that there is no reasonable chance for recovery. The pacemaker is keeping his heart going. The man left no advance directive, but discussed end of life treatment with his family. They say that he would not want to be kept alive on “machines.” The care team wonders if they should turn the pacemaker off. Is it ethically permissible for the care team to do so?

Baby

Our case this week involves a premature baby who experienced lack of blood flow to the brain, and thus has a very poor neurologic prognosis. To prevent possible seizures, the baby was given a loading dose of Phenobarbital, and currently the blood levels are slightly above the therapeutic range. The baby is now on a ventilator, and there is a possibility that the family will request terminal extubation. Is that ethically permissible, in the context of a medication which can suppress a patient's drive to breathe?

Suicide attempt

A 60 year old man attempts suicide by taking a drug overdose. He is unconscious, but is starting to improve and may regain consciousness within a few weeks. However, he was not breathing for a short while after the overdose and likely sustained some brain damage, though how much cannot be said until he regains consciousness. He has left no Advance Directive. His family requests that he be taken off of life support and allowed to die. Is it OK for the care team to honor that request?

Futile Treatment?

An elderly patient has been steadily deteriorating with a number of chronic medical conditions, including kidney failure. She is now in crisis mode, and requires a surgical procedure with low chance of success in order to survive. Even if the procedure works, she will surely die within six months due to her other conditions, and will not be able to leave the hospital or a hospice. There are conflicting assessments of the patient's decision making capacity, and she doesn’t seem to express much of a preference for or against the surgical procedure. Her family wants the procedure. Should the care team perform the procedure?

Contract

A 62 year old man is admitted to the hospital with shortness of breath. His health has been deteriorating over the past five years due to a variety of irreversible conditions. One of the conditions is a chronic headache. The headache can only be controlled with high doses of Demerol, a very strong pain killer. The patient is not always good about following his doctor’s treatment program, and so the doctor made a “treatment contract” with the patient whereby the doctor agrees to give the patient the 300 mg of Demerol needed to control his pain in return for the patient following the doctor’s treatment plan for the other conditions. The patient’s doctor is vacationing in Florida, but is contacted by the hospital care team when the man is admitted. The care team believes that the dosage is dangerously high (normal doses are between 50 and 150 mg, though patients build a tolerance to it), but the patient’s doctor insists that they use it. What should the hospital care team do?

Saving a Fetus

A woman in the 20th week of pregnancy suffers a cardiac arrest and is taken to the emergency room. Despite efforts to revive her, she dies. Some in the hospital staff want to keep her on life support long enough for the fetus to become viable and remove it. The baby’s father is unknown, and she has no other family members that would step forward to take care of the baby. Is it permissible for the hospital to keep her on life support?

Defective Newborn

A baby goes into cardiac arrest immediately after birth and must be revived. The baby is now breathing with the aid of a ventilator. However, the time spent without breathing has probably left her with severe brain damage. Moreover, blood tests indicate the presence of a rare genetic defect for which there is no chance of survival past ten years old. Her parents are of the religious belief that as soon as someone stops breathing, their soul leaves their body. So for them she is already dead, and they tell the doctors to remove the vent. What should the doctors do?

Despondent Family

A 10 year old boy is admitted to the hospital after being hit by a car. The boy lapses into a coma and is put on life support. His condition continues to deteriorate and a week later is declared dead by his physician after loss of brain stem function. However, he continues to breathe with the aid of machines. The physician notifies the boy’s family that he will take the boy off of life support. The father replies that doctors today have amazing machines that can do anything, and he thinks there is hope that they can bring him back. A sister who is a nurse at a hospital swears that she has seen others on life support recover. An hour later the doctor receives a call from a lawyer who tells him that if he takes the boy off of life support, “I will see you in jail.” What should the doctor do?