This module covers some of the very basic ethical dimensions of caring for patients at the end of life.
WATCH: Begin by watching this Mediasite recording which will introduce many of the key terms, including: medical futility, withdrawing and withholding life sustaining treatment, aid in dying, euthanasia.
READ: now that you’ve had a brief introduction of the terms, it is time for a deeper dive. Start by taking a deeper look at “futility” with the following article: Ethics in Medicine article “Futility” http://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/65. This term is used frequently in medicine, but there is much debate about the usefulness, accuracy, and potential bias that may come with the terminology.
READ: Tomlinson, T & H. Brody. Futility and the Ethics of Resuscitation. JAMA. 1990;264: 1276-1280. This article is older, but the issues it expresses continue to ring true today, especially as medical technology continues to advance, bringing with it new versions of old ethical issues.
CASE ANALYSIS: now it is time to take what you have learned so far and dig into a case.
**Assume daughter is the legal next of kin; that Mrs. Smith does not have advance directives, & that Mrs. Smith and her daughter have never discussed Mrs. Smith’s wishes under such circumstances. Also assume there is unanimous agreement among treating team/s regarding recommendation for DNAR, etc. Limit your response to the question of DNAR**
Mrs. Smith was 46 when she suffered a cardiac arrest at home. Her 20-year-old daughter was with her at the time and called 911. Mrs. Smith was resuscitated by the paramedics and rushed to the nearest hospital, but had suffered severe loss of oxygen to the brain during the episode. She was admitted to the intensive care unit (ICU) and required intubation and mechanical ventilation. An EKG revealed that Mrs. Smith had long QT syndrome, which her daughter said had never been diagnosed. Her daughter insisted that “everything be done” for her mother.
After 2 months in the ICU, Mrs. Smith’s brain functioning had not returned or shown improvement; she had not awakened or been conscious of where she was or who was in the room. Mrs. Smith’s care had been complicated by infections from the intravenous lines into and from her body, kidney failure and the need for dialysis, and worsening heart function that required an intra-aortic balloon pump. Her physicians judged that further treatment, especially CPR, would be futile; it was highly unlikely that Mrs. Smith would leave the hospital alive, or, if she did, it was likely that she would return within days or weeks. Mrs. Smith was too sick to be placed in an outpatient center and remained in the medical ICU.
The medical team, treating complication upon complication, believed they were not helping Mrs. Smith heal in any way. They felt that continuing aggressive treatment violated medicine’s fundamental “first-do-no-harm” precept. When end-of-life care measures such as comfort care, withdrawing treatments, or assigning do-not-resuscitate status to Mrs. Smith were suggested, her daughter became extremely upset, saying “My mom gave me life, how can I take hers away?” At one point her daughter broke down and said, “I would rather visit my mom in the hospital than in the graveyard.” (Prager, K. Virtual Mentor; AMA J of Ethics Dec 2013 15:12:1022-1026)
Consider the following questions.
- Is CPR medically futile in this case? By which definition of futility?
- What actions should the physician take to provide support to Mrs. Smith’s daughter while also encouraging withholding/withdrawal of some medical interventions?
- If Mrs. Smith’s daughter and the physician cannot come to agreement, should CPR be withheld over the objections of Mrs. Smith’s daughter? Why or why not?
If you’re interested in reading more in this area, here are some recommendations (not required)…
- Back, AL & RM Arnold. Dealing with Conflict in Caring for the Seriously Ill: “It Was Just Out of the Question”JAMA 2005. 293:11, 1374-1381.
- Aid in Dying statistics at https://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct