Case Studies: Respect for Autonomy

Case 1:

A 90 year old female, Mrs. Ruth, from home with her daughter, is admitted to hospital after sustaining a hip fracture. She has a history of chronic obstructive pulmonary disease on home oxygen and moderate to severe aortic stenosis.  (Obstruction of blood flow through part of the heart) She undergoes urgent hemiarthroplasty (hip surgery) with an uneventful operative course.

The patient and her family are of Jewish background. The patient’s daughter is her primary caregiver and has financial power-of-attorney, but it is not known whether she has formal power of attorney for personal care.  Concerns have been raised to the ICU team about the possibility of elder abuse in the home by the patient’s daughter.

Unfortunately, on postoperative day 4, the patient develops delirium with respiratory failure secondary to hospital acquired pneumonia and pulmonary edema. (Fluid in the lungs) Her goals of care were not assessed pre-operatively.  She is admitted to the ICU for non-invasive positive pressure ventilation for 48 hours, and then deteriorates and is intubated. After 48 hours of ventilation, it was determined that due to the severity of her underlying cardio-pulmonary status (COPD and aortic stenosis), ventilator weaning would be difficult and further ventilation would be futile.

The patient’s daughter is insistent on continuing all forms of life support, including mechanical ventilation and even extracorporeal membranous oxygenation (does the work of the lungs) if indicated. However, the Mrs Ruth’s delirium clears within the next 24 hours of intubation, and she is now competent, although still mechanically ventilated. She communicated to the ICU team that she preferred 1-way extubation (removal of the ventilator) and comfort care.  This was communicated in writing to the ICU team, and was consistent over time with other care providers.  The patient went as far to demand the extubation over the next hour, which was felt to be reasonable by the ICU team.

The patient’s daughter was informed of this decision, and stated that she could not come to the hospital for 2 hours, and in the meantime, that the patient must remain intubated.

At this point, the ICU team concurred with the patient’s wishes, and extubated her before her daughter was able to come to the hospital.

The daughter was angry at the team’s decision, and requested that the patient be re-intubated if she deteriorated. When the daughter arrived at the hospital, the patient and daughter were able to converse, and the patient then agreed to re-intubation if she deteriorated.

What are some of the ethical issues in this case?

• Who should make decisions in this situation? Should the ICU team have extubated the patient?
• Do religious beliefs constitute a justification for demanding treatment when it is not indicated?
• Does the change in the patient’s decision mean that she lacked the capacity to make the decision in the first place, or that she was not well informed?

Case 2:

An 86-year-old female patient admitted to hospital due to an increasing inability to cope at home and recent fall in which she suffered a broken hip. She has previously been diagnosed with COPD, hypertension and increasing cognitive deficits.  While in recovery in hospital, an abdominal mass has been found (malignancy suspected but not confirmed), she has had a decrease in her ability to care for herself, difficulty swallowing with increasing aspiration risk, early stages of renal failure and an exacerbation of her cognitive issues.  The patient does not have a formal Advance Directive nor has she assigned a Power of Attorney.  She has three daughters and one son who is a cardiologist and lives out of the province.  The daughters have demanded that the patient be a full code, requested that transfer be made to ICU with a PEG tube placed and dialysis started should it be required.  The son phoned you over the weekend and stated that given his mothers age and complex medical situation he expects that she would be provided symptom management and comfort care but that no aggressive measures should be undertaken to interfere with the natural decline and progression of his mother’s diseases.  He has requested regular updates regarding her status and any interventions or treatments proposed.

What are some of the ethical issues in this case?

• Does ‘increasing cognitive defects’ = lack of capacity?
• Are any ethical principles in conflict? Autonomy? Beneficence? Nonmaleficence?
• Can an SDM demand treatment?
• Who is responsible for proposing a plan of care?

Case 3:

Case 1: Mr. Jones is alert, aware, and capable of making his own health care decisions. Although there is an order for medications to treat his heart condition, Mr. Jones refuses these medications daily. On one visit, his family members notice that he is not receiving these medications, and demand that you hide them in his mashed potatoes so that he receives them.

Case 2: Mr. Smith is a resident on your unit with advanced dementia who is no longer able to appreciate and understand his health care decisions. Because of this, he has his eldest daughter – who is his Power of Attorney (POA) – making these decisions on his behalf. Like Mr. Jones, Mr. Smith has an order for medications to treat his heart condition, but refuses these medications daily and swings at any staff member who attempts to come close with those medications; he has thus not been receiving them. On a visit from his POA, she notices that he is not being made to take his medication, and demands that you hide them in his mashed potatoes so that he receives them.

What are some of the ethical issues in these cases?

• Is there a moral difference between these two cases in the attempt to deceive either resident?
• Is it perhaps more wrong to deceive Mr. Jones than Mr. Smith, or vice versa?

Other general questions:

• Does this resident have the ability to make their own health care decisions?
• Why would we consider telling a ‘white lie’ to this person in the first place?
• Is there any benefit to telling a ‘white lie’?
• What harm will come by telling the resident this ‘white lie’?
• What harm would come to the resident if we do not tell them the ‘white lie’?
• Will the benefits of telling a ‘white lie’ in this situation outweigh the harms?

Case 4:

Mr. Smithwick is an 86-year-old patient who lives alone, and who was admitted to your hospital after a fall left him with a fractured hip. He has had multiple admissions to Emergency that were the result of mobility issues, and being able to safely move about in his three-storey home. He is well aware of the risks of living in his current residence, and is capable of making decisions involving his health care, including discharge. Although Mr. Smithwick no longer requires medical care from your hospital, the team feels uncomfortable discharging him home, and believes that he would benefit, and be at far less risk of falls in long-term care.

What are some of the ethical issues in this case?

• Does the team have an obligation to protect Mr. Smithwick from (potentially) avoidable risk?
• Does Mr. Smithwick, on the other hand, have a right to live at risk?
• What safeguards are in place to ensure Mr. Smithwick is making an informed decision?
• What mechanisms can be implemented to address the potential moral distress of staff?

Case 5:

A 75-year-old healthy male was working on the roof of his house when he slipped and fell 10 ft. to the ground. He was knocked unconscious. When the paramedics arrived he was awake but confused. His vital signs were stable (e.g., Glasgow Coma Scale [GCS] score of 14). He was immobilized with a C-collar and backboard and taken to the ED. Shortly after arrival in the ED he became more confused, then sleepy. His GCS score decreased from 14 to 10. The attending emergency physician was concerned that perhaps the patient had a significant head injury and was in the process of arranging for a CT scan when the patient’s wife arrived. The patient’s condition continued to deteriorate, to a GCS score of 8. The emergency physician prepared to intubate him, but when she discussed this with the patient’s wife, the wife became upset and stated that her husband had a “living will,” which specifies that, if he became critically ill, he would not want any resuscitative interventions, including intubation.

*From: Pauls, M. et al. (2002). Ethics in the Trenches: preparing for ethical challenges in the emergency department. CJEM, 4:1, Pg. 45.

What are some of the ethical issues in this case?

• Was the patient adequately informed when they declared their wishes? Did they put these wishes into a particular context? That is, were they intended for reversible, or irreversible illness?
• Is the patient’s wife required to make a decision in the best interests of the patient? Who decides what is ‘best’?

Case 6:

The patient is a 27-year-old man who has severe schizophrenic illness and type-I diabetes. Before treatment in your secure treatment unit, he was treated successively in different settings with good success. He had been brought to your secure treatment unit after a near-fatal assault on a patient in another hospital. His stay has been characterised by periods of relative health alternating with periods of withdrawal and aggression, at which time he would become very depressed. During these periods, he talks about hearing “voices” which he claims were the reason he attacked others physically, including staff, in the past.

He also refuses to accept his insulin during periods of depression but agrees to his schizophrenia medication; this is appropriately managing the illness, despite the periods of withdrawal and aggression. The only treatment that helps him to recover to some degree from his depressive episodes is electroconvulsive therapy (ECT), even though he had once expressed his wish to not receive it when he was capable. Although he has been found incapable of consenting to treatment during depressive episodes, he refuses ECT each time it is presented, and he has to be forcibly restrained while his insulin is administered.

The staff find it distressing to have to forcibly restrain the patient so often, and to inject him with insulin against his will. They feel that restraining him compromises their caring relationship with him. Also, they feel uncomfortable in having to inject him with insulin, which he needs for his type-I diabetes, since he is adamantly refusing. Unfortunately, this is the only way to keep him from ketoacidosis until he recovers from his depression after a few weeks of ECT.

What are some of the ethical issues in this case?

• Which of the treatments (if not all) should/should not be administered?
• When capable, what did the patient refuse exactly? What did his refusal mean?
• What documentation is available?
• Do prior expressed capable wishes apply only to somatic disease or do they also apply to mental health conditions?
• Does the patient have the right to refuse psychiatric intervention in prior expressed wishes from a mental health point of view? If so, what if he becomes violent?
• Would this only apply to mental health patients with periods of stability? What if the patient became permanently incapable?
• What alternatives are available to this patient (to the ECT) and were these provided to him as options when capable and deciding?

Case 7:

A 65 year-old female patient was admitted to hospital in mid-July with a diagnosis of Metastatic Stomach Cancer and for not being able to meet her caloric intake at home. This patient is married, with three adult children (two in town, one in a different city, 6 hours away). She is a very proud and attentive grandma to two grandchildren, her own mother is still alive, and she has four siblings all living in Montreal. This patient has been followed in Montreal by an Oncologist for the past 3 years. 80% of her stomach was removed, and she currently has a CADD pump for pain – a small pump designed to deliver medication when patient’s are up and about. In developing a treatment plan with this patient, her physician first considered two options: 1) Peg tube – This was not considered medically appropriate because of the significant risks involved, or 2) Naso-Gastric tube – This was not an acceptable option, according to the patient, because of the risks involved and impact on her quality of life.

At this point Total Parenteral Nutrition (TPN) was initiated as the only appropriate option to fulfil the patient’s nutritional needs. TPN is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth.

The patient remained in hospital and received TPN, with the goal of receiving home TPN through the local home-care provider. A referral was made for this home service, but due to the short life expectancy of the patient, she did not meet the required criteria and was not added to the waiting list. Despite this the patient’s goals remained consistent: enjoy an acceptable quality of life, be with and see her grand children, and be able to go home so that she can spend her final days with her family.

What are some of the ethical issues in this case?

• Without having more information, can we know if the process for assessing home-TPN eligibility is fair?
• Without knowing that TPN would not be provided at home, was this patient fully informed in making a decision to consent to the initial TPN in hospital? That is, would her decision to initially pursue it have changed, if she knew that she would be required to receive it in hospital?
• How might moral distress impact the health care team (or others) in this situation? They all believe the “right thing” to do is to allow the patient to go home for her final weeks/months of life, but they are unable to make this a reality.

Case 8:

Home care services were appropriately scheduled for Mr. Deere according to his assessed care needs and preferences for time/day.  After several months of receiving services, Mr. Deere claimed that he wanted only certain staff to provide service. The reasons provided were simply that he preferred the company of certain staff over others. In an attempt to ensure client-centered care, Mr. Deere’s request was addressed such that all of his attendants were those that he agreed with. This caused significant adjustments to the service schedules of other staff.

What ethical issues might be present in this case?

• Is the organization required to meet such client requests in the pursuit of client-centred care?
• Does the client have the right to expect accommodation for preferences?
• Is the organization able to meet such preferences for all of its other clients? If not, why is this client being treated differently? Is it fair?

Case 9:

One of your clients recently returned home from hospital with increased care needs. She is unwilling to assist with self-management and expects staff to respond to the higher care needs as she requests. Currently there has been no reassessment for increased financial support to pay for additional hours of service.

What are some of the ethical issues in this case?

• How can we balance the increasing needs of individual clients against zero financial increases?
• Client care needs are decided following a formal assessment process and cannot/should not be adjusted without re-assessment. Can you appropriately meet this client’s needs, and ensure limited resources are used appropriately, without such an assessment?