The Decision To Let Go

The Decision To Let Go

The decision to let a loved one go is often based on emotions, beliefs and if requested by the patient the terms set by an advance directive or a living will.  Clinical ethicists are consulted when the lines become blurred.  This case represents a combination of consultations where all identifiers have been changed.

Patient: Michelle Connolly
DOB: 3/26/1977
MR # 234564
Requestor: C. Witter, RN
Attending Physician: Dr. Tieter
Consultant: Christina Sisti
Ethical Dilemma:
The patient is at end care for cancer.  The patient's husband has requested that his wife be a full code.  A full code is when everything possible is done to keep a patient alive.  Is it the right decision to continue to give care to a terminally ill patient?
Description:
Medical Indications:  Patient is a 40-year-old woman who has cancer of the appendix.  The patient is receiving full ventilator  support, vasorepressors and fluids.  The patient is unresponsive, not on sedatives and responds to painful stimuli only.
Patient Preferences: 
Patient lacks capacity.  Prior to being admitted patient had not spoken to her husband or her doctor about her medical wishes or if she would want a Do Not Resuscitate, DNR, to be put in place. A DNR is a medical instruction written by a doctor.  It instructs medical professionals to not initiate cardiopulmonary resuscitation, CPR, if the patient’s heart stops or if the patient stops breathing.  Her husband has been named as her health surrogate and remains unsure about what he should do regarding her DNR.
Quality of Life:  
Patient is currently on ventilator support, vasorepressors and fluids.  The patient is unresponsive and only responds to painful stimuli.  
Contextual Features:  
Patient is a 40-year-old mother and has children.  She is married and is active in her religious beliefs.  Factors that would influence her husband’s decision would include approval from his priest and understanding the medical benefits and burdens of his wife’s care.
Assessment:
The patient is  responsive only to painful stimuli.  Her vitals show no improvement since she has been admitted to the hospital.  Is it ethically permissible to run a full code on a person who is terminal?
Discussion and Analysis:
Ms. Connolly’s husband is responsible for deciding whether or not his wife should receive a full code.  He is being asked to act as her surrogate and act in her best interest.  Mr. Connolly must decide whether or not it is acceptable to choose to put a DNR in place despite not knowing his wife’s wishes.  
Mr. Connolly is relying on his faith to make his decision because he does not want to accept that his wife is dying and he wants to believe that she could die.  He is waiting for a miracle to happen despite also understanding what his wife’s prognosis is.  He shows signs of wanting to act in her best interest but seems hesitant to act upon those interests.
After a discussion, Mr. Connolly does understand his wife’s prognosis, wants to prevent her from being in any more pain and is ready to take the necessary steps to act in her best interest.
Recommendations:
Mr. Connolly seems as if he would be willing to sign the DNR.
Meet with Mr. Connolly tomorrow in the chapel and follow up on having him sign the DNR.

Reflection:
Families often avoid conversations regarding death.  When people are young, they don’t expect anything to happen to them, yet accidents and illness do occur.  It is important to have a conversation with loved ones regarding end of life issues.  Once a tragedy takes place, or a person becomes ill there are too many other concerns, and the conversation about end of life care falls to the wayside.  The time to talk about types of care is when we are healthy and can exercise our autonomy to set up a treatment plan for a time when we are incapacitated.
 

Life Measured

Life Measured

Interview: Dr. Flores Pt. 2

Interview: Dr. Flores Pt. 2

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