UW Ethics in Medicine CASE STUDY
SCENARIOS QUESTIONS & ANSWERS
Advance Care Planning and Advance Directives:
An elderly woman with chronic kidney disease told her daughters that if she ever ended
up with dementia she wouldn't want to live like that. Years later she developed senile
dementia and moved into a nursing home. Although she did not recognize family or
friends, she enjoyed the company of others and the nursing home's cat. When her
kidneys stopped functioning, staff at the nursing home expressed ambivalence about
the value of kidney dialysis, yet asked her daughters whether their mother should be
started on dialysis.
Should the daughters consider her previously stated wishes as an advance directive?
What questions should health care providers and family members ask to clarify patient
values and preferences so that they can be more easily applied in the future? -
ANSWERSThe daughters should consider her previously stated wishes as well as her
current best interests. The daughters don't know how to proceed because they did not
have the advance care planning conversation that clarified what their mother meant
when she said that she wouldn't want to live with dementia. Was it the cognitive
problems, the problems with self care, living in an institution, or the sense that living with
dementia would not bring any joy? Without knowing this, the daughters are unprepared
to step into her mother's shoes. However, asking the daughters to describe their mother
and what brought her enjoyment and meaning throughout her life might help clarify the
meaning of her words. Without really knowing their mother's wishes or feeling
comfortable about what she would want as a goal of care under the present
circumstances, the decision about dialysis is difficult. The daughters may choose to
approve dialysis with the proviso that future triggers could lead to its discontinuation.
For example, if her current quality of life deteriorates to the point where she is no longer
experiencing joy, or if her behavior on dialysis requires early termination of the dialysis
sessions, it may be appropriate to discontinue dialysis at that time
Advance Care Planning and Advance Directives:
,A patient who has coronary artery disease and congestive heart failure shows his
physician his advance directive that states he wants to receive cardiopulmonary
resuscitation and other forms of life-sustaining treatment.
What should the doctor say to the patient in response to this? - ANSWERSThe patient's
expression of a preference should be explored to understand its origins. It is possible
that the patient believes, based on television shows, that CPR is usually effective. If this
is the case, the doctor should educate the patient about the near futility of CPR under
these circumstances. However, the physician may learn that the patient has deeply held
beliefs that suggest that not trying to live is tantamount to committing suicide which he
perceives as morally wrong. In this situation, the doctor might want to ask the patient to
explore this further with him and perhaps the chaplain.
Advance Care Planning and Advance Directives:
A patient tells his family that he would never want to be "kept alive like a vegetable".
What is meant by the term "vegetable"? - ANSWERSThe use of this expression is as
vague as saying, "I don't want any heroics or extraordinary treatments" or, "Pull the plug
if I'm ever in ...." If these types of comments in advance care planning discussions are
not clarified, they are not helpful. For some patients being a "vegetable" means being in
a coma, for others it means not being able to read. Gently discuss the patient's hopes,
fears, and specific preferences in order to clarify the meaning of the term and the
patient's preferences for end-of-life care.
Breaking Bad News:
Jose is a 62-year-old man who just had a needle biopsy of the pancreas showing
adenocarcinoma. You run into his brother in the hall, and he begs you not to tell Jose
because the knowledge would kill him even faster. A family conference to discuss the
prognosis is already scheduled for later that afternoon.
How should you handle this? - ANSWERSIt is common for family members to want to
protect their loved ones from bad news, but this is not always what the patient himself
would want. It would be reasonable to tell Jose's brother that withholding information
can be very bad because it creates a climate of dishonesty between the patient and
family and medical caregivers; also, that the only way for Jose to have a voice in the
decision making is for him to understand the medical situation. Ask Jose how he wants
to handle the information in front of the rest of the family, and allow for some family
discussion time for this matter.
In some cultures it is considered dangerous to talk about prognoses and to name
illnesses (e.g., the Navajo). If you suspect a cultural issue it is better to find someone
who knows how to handle the issue in a culturally sensitive way than to assume that
you should simply refrain from providing medical information. For many invasive
medical interventions which require a patient to critically weigh burdens and benefits, a
patient will need to have some direct knowledge of their disease in Western terms in
order to consider treatment options.
Breaking Bad News:
, You are a 25-year-old female medical student doing a rotation in an HIV clinic. Sara is a
30-year-old woman with advanced HIV who dropped out of college after she found that
she contracted HIV from her husband, who has hemophilia. In talking to Sara, it turns
out you share a number of things--you are from the same part of Montana originally,
also have young children, and like to cook. Later in the visit, when you suggest that she
will need some blood tests, she gets very angry and says, "What would you know about
this?"
What happened? - ANSWERSAlthough the protocol for breaking bad news is helpful, it
doesn't cover everything. There are instances when you may provoke a reaction from a
patient because you remind them of someone else--or, as in this case, themselves. In
these instances it can be helpful to step back, get another perspective (perhaps from
someone in clinic who has known Sara), and try not to take this reaction too personally--
even though it is likely that Sara will know how to really bother you.
Clinical Ethics and Law:
CASE 1: DISAGREEMENT AMONG SURROGATE DECISION-MAKERS AND WITH
ADVANCE DIRECTIVE/END OF LIFE/FUTILITY:
A 72 year old woman was admitted to the Neurological Intensive Care Unit following a
cerebral hemorrhage which left her with severe brain damage and ventilator dependent.
One year before this event, the patient and her husband had drawn up "living wills" with
an attorney. She was diagnosed by her treating physician as being in a permanent
unconscious condition. The patient's living will specified that the patient did not want
ventilator support or other artificial life support in the event of a permanent unconscious
condition or terminal condition.
The patient's husband is her legal next of kin and the person with surrogate decision-
making authority. When the living will was discussed with him, he insisted that the
patient had not intended for the document to be used in a situation like the -
ANSWERSThe ethical and legal parameters in Case 1 are informed consent, surrogate
decision-making and the patient's ability to direct her care - expressed in law as a liberty
or privacy right and in clinical ethics as respect for patient autonomy. While the details
of each case will determine the advice provided, the difficult issues raised in Case 1
prompt consideration of a number clinical ethics and legal issues.
Specific clinical ethics and legal issues:
The patient is unable to provide informed consent for medical care. Informed consent
means making a medical treatment choice and includes the choice of non-treatment.
What is known about the patient's wishes for continued medical treatment under her
current circumstances?
Her providers, referencing intuitional policy, thought ventilator support and CPR were
medically futile. A provider's determination of medical futility means that treatment is
highly unlikely to provide overall benefit to the patient. Such determinations are case-
specific, and should be thoroughly discussed with surrogate decision-makers. While
providers may not be obligated to provide medically futile interventions, depending upon
