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?