Some Issues Raised:
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Advance Directives
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Benefit of Treatment
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Communication
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DNR
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Durable Power of Attorney for Healthcare
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Futility
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Patient Dignity
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Patient Values
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Patient Vulnerability
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Physician as Patient Advocate
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Self-Determination
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Terminal Condition
Mr. Carlson is 73 years old and has been diagnosed with lymphoma.
He received one course of chemotherapy but was told that even with another
course of chemotherapy the best he could hope for was another 6 months
to live. He had been living alone in Reno but decided to move to
Cleveland to live out his days with his niece who is his only relative.
After settling in his new home he began to suffer from congestive heart
failure and went to Dr. Morrow, a local oncologist for help. Dr. Morrow
ordered hospitalization and Mr. Carlson agreed but insisted that he be
made DNR upon admission. His niece agreed with his request and presented
Dr. Morrow with a copy of her uncle's living will and durable power of
attorney for healthcare (appointing her as the attorney-in-fact) which
he had signed in Nevada. However, Dr. Morrow talked Mr. Carlson into being
a full code "for a while" so his situation could be assessed. After three
days Mr. Carlson arrested and he was resuscitated and placed on a ventilator.
His niece requested again that he be made DNR. A neurological consult revealed
that his EEG was so bad that, even if he could be weaned from the ventilator,
his mental status would be highly impaired. Dr. Morrow still refused to
make him DNR and the next day when his kidneys suddenly ceased functioning
Mr. Carlson was sent for dialysis without the consent of his niece. While
receiving dialysis his blood pressure bottomed out and he was given vasopressors
to restore it. Another neurological consult revealed an even more compromised
EEG which indicated that he had a 93% chance of being vegetative and a
7% chance of severe mental impairment with 0% chance of returning to his
previous level of functioning.
Some Discussion Questions:
1. In view of the Patient Self-Determination Act what kind of information
should have been given to Mr. Carlson when he was admitted to the hospital?
2. How should the presentation of Mr. Carlson's advance directive
have been handled by the hospital?
3. What were Dr. Morrow's obligations to Mr. Carlson in light of
his advance directive?
4. What were Dr. Morrow's obligations to Mr. Carlson's niece?
5. What could Mr. Carlson and his niece have done when Mr. Carlson
came to Cleveland to insure that his advance directive would be honored?
6. What special problems might a Nevada advance directive present
for compliance in Ohio?
7. How do the principles of autonomy, beneficence, and justice figure
into this case? Which principle(s) should govern the decisions made in
this case?
8. What strategies would you implement to bring this case to a resolution
which maximizes the well-being of the patient?
9. How might an ethics consultation
be helpful in resolving the disputes in this case?