Paper 2: Clinical Ethics Case Study
Clinical Case Presentation
Ed is a 67 year-old Caucasian male with multiple como
id health conditions including diabetes, high blood pressure, and vision and hearing impairment. He is developmentally delayed such that he functions at about a 10-year old level. He has been living in a nursing home for the last seven years, but was recently admitted to the hospital for lung congestion and a possible lung infection. Upon admission to the hospital Ed was running a fever and his oxygen levels were low in his blood. Ed was seen by Dr. Goldstein, who has treated Ed in the past. Upon physical examination, Dr. Goldstein found that Ed had lost control over his esophagus, and food and water were going in to his lungs when he swallowed. Dr. Goldstein determined that Ed had developed acute pneumonia and at the time of admission was critically ill. The pneumonia was treatable with antibiotic therapy, but in order to do so, Ed would need to be placed on a ventilator and have a feeding tube inserted. This could be done under sedation, to alleviate suffering to the patient. When Dr. Goldstein shared the diagnosis and treatment options with Ed, he had difficulty maintaining eye contact with the physician and Dr. Goldstein was not entirely convinced that Ed comprehended what he was telling him. Ed stared at Dr. Goldstein, blinking several times. One eye was drifting off to look into the corner of the room, and the other eye was focused on Dr. Goldstein. The physician reiterated his message in a louder tone of voice, emphasizing that Ed was very sick and that he would need to be placed on a ventilator and feeding tubes in order to get better, to which, Ed replied: “Go away! No tubes! No tubes!”
Dr. Goldstein reviewed Ed’s health record and located Ed’s advanced directives, completed seven years ago when he was moved to the nursing home. The advanced directives were developed with the help of a patient advocate and clearly indicated that he did not want a ventilator, a feeding tube, or drastic cardiopulmonary measures such as CPR. In addition, Ed had a Durable Power of Attorney on file, in which he stated he wanted his younger
other, Bert, to make medical decisions for him in the event he was no longer able to do so for himself. Dr. Goldstein determined that the situation was declining rapidly and called Bert to explain Ed’s cu
ent situation.
Bert is a 63 year-old single male with multiple como
id health conditions including Crohn’s Disease, arterial damage, and major blockages in the arteries feeding his kidneys. It is clear to Dr. Goldstein that Bert doesn’t like to make decisions: when Dr. Goldstein explained the critical situation Bert asked if he could think about it and decide the following day. Dr. Goldstein continued to explain the critical nature of the situation to Bert, trying to convince him of his position, and after some discussion about Dr. Goldstein’s assessment of the potential risks and benefits of the different treatment options, Bert agreed he would drive to the hospital to make a decision. Before driving to the hospital, Bert called their nephew, Eric (the son of Bert and Ed’s sister) and left a vague voicemail explaining the situation. Eric received the voicemail, immediately jumped in his car and was able to get to the hospital before Bert did. He intercepted Dr. Goldstein at the Intensive Care Unit and asked to be apprised of the case. Dr. Goldstein’s deemed that Eric appeared quite competent and could likely help him “sway” Bert to agreeing to his course of action.
Chief Ethical issues
The chief ethical issue in this case is determining whether or not Ed is cu
ently capable of making his own medical decisions. Should Ed’s stated preferences and/or advanced directives be followed, or should the medical decision making be turned over to his
other, Bert? If they are turned over to Bert, should Bert follow Ed’s wishes to not be placed on a ventilator and feeding tube, or should Bert contradict Ed’s wishes and follow the recommendations of the doctor?
Medical indications for Intervention
The patient, Ed, clearly has pneumonia. There are no differential medical diagnoses. The disease is a potentially curable acute emergency and without any medical intervention, Ed will likely only live a one to two weeks longer. The goal of a medical intervention would be to cure the pneumonia and prevent an untimely death. If a medical intervention is performed, Ed would be placed on a ventilator and feeding tube--at least temporarily, supporting him enough to get him back to his baseline functioning, as he is simultaneously treated with antibiotics for the lung infection. What is not clear is whether or not the esophageal condition causing him to swallow inco
ectly is a persistent condition that will require Ed to be on a ventilator for the rest of his life. Another goal of the care could be to relieve symptoms and suffering caused by the cu
ent condition, providing relief until Ed dies, without performing any invasive medical procedures.
Patient Preferences for Treatment
The treating doctor has described the diagnosis and risks and benefits of treatment options for the cu
ent situation, but it is not clear that he fully understands the information being provided to him about his condition. He has not given consent to any medical procedure. In fact, he has explicitly stated he doesn’t want any “tubes”. He is cu
ently unwilling to cooperate with medical treatment. According to the doctor’s medical opinion, above and beyond any developmental disability, Ed’s infection is preventing him from having decisional capacity at this moment. However, despite the opinion of the doctor that Ed is cu
ently incapable of making a medical decision, Ed has advanced directives in place, which were created several years ago with a patient advocate. In his advanced directives he clearly indicated that he does not want to be put on a ventilator or have a feeding tube placed. The appropriate su
ogate is Bert, Ed’s
other, as stated in his Durable Power of Attorney.
Quality of Life Considerations
This is not a simple case of pneumonia that can be treated with antibiotic therapy alone. Due to the esophageal abnormality causing the lung infection, without invasive medical intervention, Ed will die within one to two weeks. With the intervention of the ventilator and feeding tube, it is possible that Ed’s lung functioning could be supported enough for his pneumonia to resolve. However, it isn’t clear whether or not Ed has a defective gag reflex, a condition that would require Ed to be on a ventilator and feeding tube for the remainder of his life even after the pneumonia resolved. This question cannot be answered until the medical intervention takes place and the cu
ent pneumonia infection is healed. Ed’s cu
ent mental status and his developmental stage could bias the provider’s evaluation of the patient’s quality of life. A complicating factor in this case is the fact that Ed’s
other Bert, his su
ogate, is also in poor health. If Bert should also become suddenly ill, Dr. Goldstein would need to make a decision about who was the most appropriate person to make medical decisions for Ed. In this case, I believe the advanced directives are the grounds upon which the care team and Ed’s family, most specifically his
other, who Ed has stated should be his su
ogate decision maker, should presume what Ed’s desires are for quality of life.
Contextual Features
There are no obvious professional or business interests that might create conflicts of interest in Ed’s clinical treatment (or non-treatment). Beyond Ed, Dr. Goldstein and other care team members, the interested parties in the clinical relationship are Ed’s
other, Bert, Ed’s sister and Ed’s nephew, Eric. Bert is critical because he has been granted Durable Power of Attorney to make medical decisions for Ed in the event he was no longer able to do so for himself. At this point, unless Ed has signed a HIPAA authorization form, Dr. Goldstein should only divulge Ed’s medical information to Bert. It is up to Bert, then, if he wants to share the information with Ed’s nephew (who has a
ived at the hospital first) or Ed’s sister. There are no obvious financial factors that create conflicts of interest in the clinical decision. There are no problems of resource allocation or religious issues.
The greatest contextual issue here is that Dr. Goldstein clearly wants to place Ed on a ventilator, and could use his influence to convince Bert to go against Ed’s wishes and intubate him. With Bert being in poor health it is possible that this could affect his capacity to make a sound decision. The other contextual issues that could arise are legal issues. If Dr. Goldstein is able to convince Bert to intubate Ed, treatment that was against Ed’s wishes moves forward and if Ed survives, legal action could be
ought against Dr. Goldstein for violating his advanced directives. On the other hand, it is also possible that Dr. Goldstein could be sued by Ed’s family for forgoing life-sustaining treatment if no action is taken.
Analysis and Recommendation for Action
Ed is very sick and if he is not placed on a ventilator and feeding tube immediately he will die. Dr. Goldstein, the treating physician, obviously has strong feelings about the course of treatment for Ed. He believes that he should be placed on a ventilator immediately in order to “save his life”. Ed has ve
ally indicated to the doctor that he doesn’t want any “tubes”. Based on the interaction with the provider, I believe it is sufficient to rely on the doctor’s medical determination that Ed doesn’t cu
ently have decisional capacity. However, Ed has clearly indicated in his advanced directives that, should he become seriously ill, he did not want a ventilator, a feeding tube, or drastic cardiopulmonary measures such as CPR. In addition, it is stated in the case that both the provider and Ed’s
other Bert have a tacit understanding that placing Ed a ventilator and feeding tubes is against what Ed would want in this situation. Based on the core bioethical principle of patient autonomy—the commitment to respect another's right to self-determine their own course of medical treatment, Dr. Goldstein should, at this point, only be providing comfort care to Ed. Dr. Goldstein’s preferences for medical intervention should not be ove
iding the fact that Ed has explicitly documented that he does not want a ventilator or feeding