Bioethics - Case Studies
Advance Care Planning & Advance Care Directives : Case 1
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?* -
answerThe daughters *SHOULD* consider her previously stated wishes as well as her
current best interests. They do not 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 would not 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 Case 2
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? - answerAdvance Care
Planning: Case 2 Discussion The 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.
- understanding origins & near futility of CPR
- patients beliefs & values, so that medical care received reflects these
- if patient has someone that they would want to elect as surrogate
Advance care planning : case 3
A patient tells his family that he would never want to be "kept alive like a vegetable".
What is meant by the term "vegetable"? - answerCase Discussion
The 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.*
Advance care directive : case 4
A 55-year-old woman who is a Jehovah's Witness is scheduled to undergo a redo aortic
valve replacement. Before the procedure, she produces an advance directive document
that states her categorical refusal to accept blood or blood products, even in the face of
impending death. This directive document names her husband, who is not of the
Jehovah's Witness faith, as her health care proxy should she be unable to communicate
her wishes. The procedure proceeds with difficulty, and the patient is postoperatively
brought to the intensive care unit (ICU), actively bleeding and requiring increasing
vasopressors and inotropes to achieve adequate perfusion. Further testing reveals a
worsening shock picture with a rising serum lactate level. The patient's husband is
informed of these events, claims that he had indicated to his wife in a prior conversation
that he would have trouble following her - answerThe rule provides that the advance
directive, like normal autonomous patient treatment decision making, should be
reviewed under each relevant circumstance. Although the patient, an avowed Jehovah's
Witness, has written that she refuses a transfusion, what is to be made of her decision
to appoint as her proxy her husband, who is not a Jehovah's Witness and had indicated
that he could not support her directive if so asked? It could be reasoned that the patient,
Advance Care Planning & Advance Care Directives : Case 1
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?* -
answerThe daughters *SHOULD* consider her previously stated wishes as well as her
current best interests. They do not 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 would not 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 Case 2
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? - answerAdvance Care
Planning: Case 2 Discussion The 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.
- understanding origins & near futility of CPR
- patients beliefs & values, so that medical care received reflects these
- if patient has someone that they would want to elect as surrogate
Advance care planning : case 3
A patient tells his family that he would never want to be "kept alive like a vegetable".
What is meant by the term "vegetable"? - answerCase Discussion
The 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.*
Advance care directive : case 4
A 55-year-old woman who is a Jehovah's Witness is scheduled to undergo a redo aortic
valve replacement. Before the procedure, she produces an advance directive document
that states her categorical refusal to accept blood or blood products, even in the face of
impending death. This directive document names her husband, who is not of the
Jehovah's Witness faith, as her health care proxy should she be unable to communicate
her wishes. The procedure proceeds with difficulty, and the patient is postoperatively
brought to the intensive care unit (ICU), actively bleeding and requiring increasing
vasopressors and inotropes to achieve adequate perfusion. Further testing reveals a
worsening shock picture with a rising serum lactate level. The patient's husband is
informed of these events, claims that he had indicated to his wife in a prior conversation
that he would have trouble following her - answerThe rule provides that the advance
directive, like normal autonomous patient treatment decision making, should be
reviewed under each relevant circumstance. Although the patient, an avowed Jehovah's
Witness, has written that she refuses a transfusion, what is to be made of her decision
to appoint as her proxy her husband, who is not a Jehovah's Witness and had indicated
that he could not support her directive if so asked? It could be reasoned that the patient,
