CLINICAL CASE FOR DISCUSSION
Howard Russell
Lawrence P. Ulrich, Ph.D.
Lawrence.Ulrich@notes.udayton.edu


Some Issues Raised:

Howard Russell is 34 years old and was diagnosed with AIDS when he became symptomatic in 1993. Ordinarily persons with AIDS will live about 21 months after they become symptomatic. Mr. Russell has lived 30 months. However, he is nearing the end. He is in the hospital and suffering from another infection and poor nutrition. He is being given antibiotics which are temporarily controlling the infection and he is being tube-fed. The prognosis is that he will not leave the hospital, the tube feedings will have to continue, the antibiotics will be useful for only a limited time, and there is a good chance that he will experience cardiac arrest in a short period of time. Upon admission, Mr. Russell agreed to a DNR order but after one week, he requested that the DNR order be reversed and that he be made a full code. His change of mind occurred when his partner returned from a business trip to Montana and discovered that Mr. Russell had been hospitalized. His partner reminded Mr. Russell that, in their many conversations about the disease which threatens him they had agreed that they would not allow him to succumb to the disease voluntarily; that they would fight against the disease as long as they possibly could and that they would never surrender to it. There is no question about Mr. Russell's decisional capacity. His physician and the medical staff think that a full code is inappropriate because of his failing condition. Their assessment is that, even if he were to survive the code, he would end his few remaining days on a ventilator. They admit that there is some chance that Mr. Russell might regain consciousness after being resuscitated even though he would be on a ventilator.

Some Discussion Questions:

1. How should a physician handle a situation where the patient changes his mind?
2. Is Mr. Russell being realistic in his assessment of his situation and his life goals?
3. Is there room for negotiation between the residents and Mr. Russell about therapeutic interventions which are futile?
4. Would a unilateral DNR order be appropriate in this case?
5. In what way is Mr. Russell experiencing a particular vulnerability as a patient?
6. Is Mr. Russell's partner a help or a hinderance as Mr. Russell is approaching his final days?
7. Are Mr. Russell's virtues as a patient of any help to him in making his end-of-life decisions?
8. What principle(s) of bioethics [autonomy, beneficence, justice, paternalism] do you think should govern this case?
9. How might the approach of feminist ethics be a help in this case?
10. What strategies would you implement to bring this case to a resolution which maximizes the well-being of the patient?
11. How might an ethics consultation be helpful in resolving the disputes in this case?