TAPM/TNMHO 2015 Ethics Case Studies

TAPM/TNMHO 2015 Ethics Case Studies

Page 2 of 6

In each of the following scenarios, the initial clinical and psychosocial facts immediately available when the ethical issue arises are outlined. Your task is to:

·  Collect additional information by asking appropriate questions;

·  Analyze the case from the medical, psycho-social human behavior, legal/policy, and ethical perspectives; and

·  Recommend a course or courses of action to the treating team, family, and institution as appropriate.

Consider use of the following format:

·  What should you do?

·  Medical Facts

·  Psycho-social Issues

·  Legal Concerns

·  Ethical Issues: Principles, Virtues

·  Recommendations

Case 1:

Sally is an 84 year old right handed female previously independent who presented to the hospital with a new left MCA CVA leaving her with residual right sided weakness and expressive/receptive aphasia. She was unable to give history but her “church friends” stated they were aware she had been “wasting away” over the past 6 to 12 months, even though they saw her eating at church socials. As she had become weaker, they were bringing her meals and she would generally eat those well too, though they noticed she far preferred the sweets! They had urged her to see her physician, but she had refused. They think she weighed around 150 pounds a year ago and she was 107 pounds on admission. Her primary physician in fact had not seen her in two years but confirmed at that time she weighed 152 pounds. He was treating her for mild essential hypertension, hyperlipidemia, and osteoarthritis. She had a prior history of cholecystectomy in her 40s and a fractured R elbow 7 or 8 years earlier. On exam she had right hemiparesis and followed some simple one step commands with her left hand, but other than acknowledging some questions with “K” and “yeah” she couldn’t reliably express herself. She mostly had a blank look to her, without smile or frown. She had no pharyngeal pooling of secretions and when offered liquids or solids, either had a single bite or sip or simply turned away.

Her church friends visited her daily at the hospital and they thought she might have a niece; however they had no contact information. Her primary doctor felt the same, but he had no contact information. Her church friends told the primary team they believed she valued her independence and would not wish her life prolonged in this state of existence. It was difficult to validate her decisional capacity given her aphasia but a 7 year old Living Will indicating a preference for comfort only if either terminal or irreversible was found in the EMR, dating back to hospitalization for her old left elbow fracture.

Based upon this document, statements by her church friends, and the patient’s overall condition, a decision was made to enroll the patient in hospice. She made her “mark” on the enrollment forms. Because there was uncertainty about her decisional capacity, the local ethics committee was asked to endorse the decision, which they did. Because she was neither eating nor drinking effectively and IV fluids were stopped, it was believed she would die within the next week or so. Her church friends did not want her to go to a nursing home and given her anticipated short life span, they agreed to stay with her at her home with the assistance of home hospice. Three days after arriving back home on home hospice, the patient’s niece showed up. She was profoundly opposed to hospice enrollment and accused the hospice of “starving” her aunt to death. She demanded the patient be taken to a new hospital where she told all she would insist on having a PEG placed.

Case 2:

Henry is a 49 yo man with progressive glioblastoma, s/p surgery, radiation and chemo, now enrolled in home hospice, cared for by his wife of 19 years, his 16 year old daughter, and the home hospice team. Over the past several days, he has shown evidence of increasing pain and confusion. He was already on dexamethasone 4 mg po twice daily, fentanyl TD at 200 mcg/hr and MSIR 20 mg/ML q 2 hours prn but is increasingly restlessness, moaning, and agitated. As you are coming in to see him for the third time this week, his wife and son greet you at the door and take you into the hallway leading to his bedroom. They look you in the eye and say, “We saw the stories on Brittany Maynard and we think she and her family had it right. Henry has had enough. He just needs this to be over. We don’t want to get you in any trouble, but we were just thinking that if you could give us an extra bottle of Roxanol, we can get it into him with some extra Ativan and this can be over. He’s dying and this is all just too hard on him. We all thought this would be over by now and this just has to stop. Will you help us please?” You can hear Henry moaning in the next room.

Case 3:

Mr. H was a 92 year old man with multiple medical problems: significant chronic kidney disease, history of nonSTEMI in November 2014 following a fall in which he fractured cervical spine, recurrent bouts of dehydration requiring IV hydration, gout, recent onset of stage II decubitus, cachexia, dysphagia. He had a history of bladder cancer 3 years prior for which he received XRT. His family had not permitted him to walk for several years since he was weaker and at high risk of falls. He ambulated via wheelchair.

He had been bed-bound since the autumn and c-spine fracture, and wore a neck brace to protect his neck when sitting upright. He had around the clock paid caregivers who were doing a great job.

Over the previous few weeks, he ate significantly less, took in less fluids, and spoke less than usual--only a few words, and would not respond to questions. He did not have any evidence of an infectious process which would require antibiotics.

HIs two daughters consulted his Internal Medicine physician who said the family had three choices: do nothing, go to hospital for another round of treatment/IV hydration, or choose hospice.

His wife, who had a small amount of cognitive impairment, tended to defer to the daughters(who had POAs), but overall wished to treat whenever possible.

The patient had an Advance Directive, executed two years prior in Florida, in which he selected the option of allowing a peaceful death if he had a terminal condition.

His elder daughter strongly advocated for IV fluids, as she saw him "bounce back" six months previously when he had his last bout of dehydration (prior to cervical fracture and AMI). The younger daughter felt that the patient had approached the time when he would wish a peaceful death. The wife sided weakly with the elder daughter. The Internal Medicine physician wrote an order for hospice using "debility" as his terminal condition.

The sons in law tried to remain neutral, but leaned more toward comfort measures, no hospitalization, and were not as invested in the hydration question.

The wife did not even remember doing the Advance Directives though she had cosigned them. Conversing with her about his wishes was not helpful.

Religious affiliation: Reform Jews.

****The ethical dilemma was over doing hydration. Was the advance directive clear enough to forego artificial hydration when he was nearing death? *****

There was debate between the daughters, and internally among the hospice team members.

The family chose hospice but hydration was the deal breaker.

The hospice did do subcutaneous hydration (not at a rate high enough to satisfy the elder daughter), but the patient proceeded to die 5 days later, comfortable and surrounded by his family.

Case 4:

56 year old male with primary diagnosis of Cirrhosis of the Liver with Co-morbs: COPD; Hx of Alcoholism & Drug Abuse; Chronic Renal Failure, Depression; Hepatitis C; HIV.

On service with us 35 days.

Transferred to us from another hospice (they were actually TNMHO members and chose us from the TNMHO directory to recommend to him)

Living in a very small, low income rent home with adult daughter as PCG. 13 year old grandson also in the home.

From the outset, PT and PCG had highly volatile relationship. They had been estranged for a number of years prior to the PT's decision to move from the Abilene, TX area to Amarillo. In Midland he had been cared for by his second wife who had determined that she could no longer provide care. PT's daughter agreed to have him live with her in Amarillo, stating she wanted to care for him until he died and perhaps repair their relationship.

PT very reluctant to having hospice staff members in home. Made it very challenging to provide care, especially as the psychosocial dynamics in the household were so intense. Lots of paranoia on the part of both PT and PCG. Consequently, for the first three weeks of care only the RNCM was allowed in the home. On hindsight, we could see that the PT's life circumstances were reminiscent of the RNCM's own childhood experiences, which created personal boundary issues for her. These issues had a great impact on the situation.

PCG was open to receiving support from hospice team but PT thwarted it at every turn. Every week, appointments were made by hospice team members other than RNCM, but were cancelled by PT at the last minute.

After an initial period during which PT's pain and symptom management was basically uncontrollable, it was determined that the PT was self-medicating with marijuana. Additional hospice team members (Social Worker and Chaplain) were finally able to gain access to the PT and the Grief Counselor had two sessions with PCG and her son in the Grief Counselor's office, not onsite at the PCG/PT's home.

Throughout the course of care, PT and family were in constant turmoil, with lots of verbal abuse and threats of physical violence. Police were called out to home to intervene twice that we were made aware of. CPS was involved in family situation because of 13 year old's truancy and behavioral issues. PT's first wife, the PCG's mother, who was on a drug rehabilitation program, was also in and out of the picture, adding to the turmoil.

At each weekend, PT would decide that he wanted to move back to Abilene, however, his wife would refuse to allow his return and the Abilene hospice was very reluctant to discuss transfer back to them. They also provided us with no background information about the family dynamics, nor the PT's ongoing use of marijuana and his non-compliance.

This non-compliance was a constant issue. Because of his disease, PT's failure to take his medications appropriately had direct effect on his cognitive abilities; the build-up of ammonia levels added to his erratic behavior and would add to an already volatile situation.

By the last two weeks of service, the PT had been "thrown out" of PCG's home and moved in with his ex-wife who was not willing to become PCG. PT declined all suggested options of living situations other than with family (long-term care facilities, etc.) and was ultimately allowed to move back in with his daughter, but this was to be temporary until he could convince his wife in Abilene to take him back.

On the last day prior to dismissal from our services, Grief Counselor was called to the home by RNCM because of the situation between PT and PCG. When GC arrived, situation was quickly out of control between the two, with GC physically separating them twice before coming to blows. During this exchange, GC was told that PT had tried twice to stab PCG and was also told that PT had been selling prescribed hospice medication in order to buy marijuana. This clarified a great deal about the difficulty we had controlling PT's pain and symptoms -- He was selling rather than taking his prescribed meds. There had been no med discrepancies as the PT had been very careful to sell the meds in direct proportion to how they were prescribed.

During this encounter, GC had been very aware that the situation was not safe for hospice staff. The PT and PCG continually moved to become physically violent with each other and the drug sales were taking place with the next-door neighbor. PCG also admitted that PT had access to guns and knives.

After this incident, an Ethics Committee meeting was called and it was determined that we would have to discharge for cause. The delivery of this decision to the PT reiterated its correctness -- PT and his ex-wife (with whom he again moved in temporarily) both became verbally abusive. PT declined all care alternatives proffered by hospice team. During this encounter, a gun and drug paraphernalia were clearly visible and accessible to PT and ex-wife.

Case 5:

A man has written in his advanced directive that he would not want any life sustaining therapies if he were in a terminal condition. He has a stroke and starts declining especially in swallow. The family is able to acknowledge this previous desire, but feel they just can’t let him die without attempting everything to see if he could recover first. So, he is given a feeding tube, which he pulls out. He gets infection and sepsis and now family has consented for treatments in the ICU including pressors, ventilator and replacement of the feeding tube.

I am the ethics chair at our institution and this was the latest one I was handed.

Case 6:

The patient was a 69 year old female with end stage Pulmonary Fibrosis. She had multiple hospital stays for exacerbations, each complicated by having to have massive doses of IV steroids which had left her with morbid obesity and diabetes. Upon going on hospice, we increased her oral steroids, but they were not helping and on an every 2 days basis had an additional concentrator added so that she had 3 10 liter / min concentrators in series running at 10 l/min each. She was put on CC for ongoing respiratory distress and became unable to swallow anything but liquids. When she reached the point of being on Morphine 20 mg q hour and Lorazepam every 2-4 hours, her family demanded that we simply take off the oxygen altogether.

Given that she was still uncomfortable I did not feel like this was appropriate for fear she would feel as if she was smothering. The family was quite adamant and so I elected to reduce the oxygen slowly.

Again, I do not feel this is a “great” ethics case, but still, there it is.