CLINICAL CASE FOR DISCUSSION
Heather W.
Lawrence P. Ulrich, Ph.D.
Lawrence.Ulrich@notes.udayton.edu


Some Issues Raised:

Heather W. is a 20-year-old woman with widely metastatic Ewing's sarcoma. She was admitted to the hospital for extreme exacerbation of ongoing hip, leg, and low back pain. She has multiple bony metastases including spinal lesions for which she received ibuprofen and increasing doses of methadone and hydromorphone. Dexamethason was administered adjunctively and she received palliative radiation therapy to her spine. He pain escalated, and her hydromorphone infusion was increased to 100 mg per hour, along with bolus doses of methadone in excess of 300 mg every two to six hours. (Cumulatively, the methadone and hydromorphone were administered in doses roughly equivalent to 1500 mg of morphine per hour.) She received some temporary pain relief but when this began to fail she complained that she could stand the pain no longer and wanted to be killed. She received a loading dose of pentobarbital (3.3 mg per kilogram) followed by an infusion (1 to 2 mg per kilogram per hour). This produced sleep with good maintenance of respiration and stable hemodynamics. Her father who was her authorized healthcare proxy decided that this approach should be continued until she died. And he wanted this terminal sedation to be unaccompanied by artificial nutrition or hydration.

Some Discussion Questions:

1. How is the principle of double effect being used in this case?
2. Has this patient reached the point where terminal sedation is the only answer?
3. In what way should the patient participate in the decision for terminal sedation?
4. Is it appropriate to withhold artificial nutrition and hydration for this patient once terminal sedation is initiated?
5. As an objective observer, what do you think should be done in this case?
6. How do the principles of autonomy, beneficence, justice, and fidelity figure into this case? Which principle(s) should govern the decisions made in this case?
7. What strategies would you implement to bring this case to a resolution which maximizes the well-being of the patient?