CLINICAL CASE FOR DISCUSSION
Ms. George
Lawrence P. Ulrich, Ph.D.
Lawrence.Ulrich@notes.udayton.edu


Some Issues Raised:

Ms. George is a 78-year-old widow with a daughter with whom she has been living for 10 years. Ms. George has a history
of cardiovascular disease including one heart attack and one moderate stroke from which she has recovered fairly well. She was admitted to the hospital with periods of dizziness. Tests reveal that she has a large dissected aortic aneurysm. The surgeons have determined that she is not a candidate for surgery because of the fragility of the aneurysm and the extensive damage to her cardiovascular system due to the long history of her disease. Ms. George does not have an advance directive and has never spoken to her daughter about end-of-life decisions. Immediately upon hospitalization Ms. George became disoriented due to another stroke and has been unable to participate in decisions about her healthcare.  Her daughter's lifestyle has been totally focused on caring for her mother. When the discussion turns to entering a DNR order on Ms. George's chart her daughter adamantly refuses to allow the DNR order to be written. She does this in spite of the fact that she is told that studies have shown that a patient in her mother's condition has a 0% chance of surviving CPR if she were to undergo cardiac arrest.

Some Discussion Questions:

1. If Ms. George is not a candidate for surgery, is she a candidate for CPR?
2. Would it be appropriate to enter a DNR order on her chart without the consent of her daughter?
3. Are the daughter's goals appropriate for initiating a treatment which has been determined to be medically futile? 4. Is there any room for negotiation between the physicians who think CPR is futile and Ms. George's daughter who wants it initiated?
5. Should CPR be offered to or discussed with a patient or surrogate if the physician decides that it is futile?
6. Is Ms. George's well-being promoted in the therapeutic decisions which have been made in this case?
7. What principle(s) of bioethics [autonomy, beneficence, justice, paternalism] do you think should govern this case?
8. What strategies would you implement to bring this case to a resolution which maximizes the well-being of the patient while still respecting the surrogate's feelings?