Some Issues Raised:
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Advance Directives
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Benefit of Treatment
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Physician as Patient Advocate
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Physician Integrity
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Nutrition/Hydration
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Surrogate Decision-making
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Withdrawing Treatment for Incompetent
Patients
Mildred D., a 78-year-old woman, suffers from diabetes, which has
been controlled largely by diet. She has a history of heart disease and
has suffered two heart attacks. She has now has a stroke, which has rendered
her obtunded and paralyzed. She must be fed through an NG tube, and the
sustenance that she receives in this way is the only thing that keeps her
going. Mildred D. had not developed an advance directive, either oral or
written, and cannot now communicate about her healthcare condition or the
direction her healthcare should take. Her condition is slowly deteriorating,
but it looks as though the dying process will be a relatively long one.
It seems that she will never return from the twilight zone in which she
now resides. Angiography indicates that a substantial portion of her brain
has been destroyed by the stroke. Her three children want to stop the tube
feedings, but the physician objects because he thinks that it is unethical
to "starve" a patient so that she will die sooner.
Some Discussion Questions:
1. Do you think that "quality of life" is an appropriate criterion
to determine the course of action in this case?
2. Are Ms. D.'s children attempting to perform euthanasia on her?
3. Will the withdrawal of the tube feedings be the cause of the
patient's death?
4. Is the patient terminally ill?
5. Are the tube feedings to be considered life-sustaining treatments?
6. If Ms. D. were to have a DNR order entered on her chart would
it be contradictory to continue the tube feedings?
7. What ethical system do you think should be utilized to resolve
this case?
8. What ethical principle(s) [autonomy, beneficence, justice, paternalism]
should govern this case?
9. What strategies would you implement to bring this case to a resolution
which maximizes the well-being of the patient?