Sample Consult

Medical Ethics Case Consultation
Generic Hospital Bioethics Committee

Presentation:
Mr. A is an 87-year-old patient who carries a diagnosis of Dementia, Alzheimer’s type and suffers from CHF, COPD, Hyperlipidemia and Diabetes Mellitus. Mr. A’s most serious problem at the present time stems from a gangrenous ulcer on his right lower extremity. Mr. A is not a surgical candidate, as his overall health condition elevates surgical risk to unacceptable levels. There is no question in the minds of treatment team members that Mr. A is terminally ill. The surgeon who was consulted regarding the ulcer indicated that there are no clinical options available to save Mr. A’s life, and that life-prolonging care could reasonably be withheld. Mr. A does have involved children, and they are accepting of their father’s situation. They have requested that IV antibiotics continue, but they have rejected the use of invasive treatments, such as enteral feeding, that would serve only to prolong the dying process. This ethics consultation was requested on the basis of concerns surrounding pain medication. If sufficient pain meds are used for Mr. A, then it is likely that he will become even more obtunded than he presently is, and that his appetite and ability to eat will be reduced. While the ID team believes that more aggressive palliative support is indicated, they are concerned about the ethical implications of suppressing Mr. A’s appetite.

Recommendations:

1. Since Mr. A lacks the capacity to make his own health care decisions it is necessary to identify an appropriate surrogate decision maker. Mr. A did not leave an advance directive, so there is no durable power of attorney for healthcare. Mr. A does not have a spouse, so the role of proxy falls to his adult children according to Virginia’s Health Care Decisions Act. The ID team believes that Mr. A’s children are capable of making good health care decisions for this patient and we have no evidence that their choices are inconsistent with the values of the patient. Therefore, we recommend that there is no ethical reason to question the authority of Mr. A’s next of kin in this regard. We recommend that their authority should be honored in this case.
    
2. Given the clinical findings in this case, we believe that the family’s request to forego life prolonging care can reasonably be construed as falling within medical standards of care and being in the patient’s best interest. Mr. A is terminally ill, and we have already recognized that death is imminent for this individual. Our highest priority, therefore, may reasonably shift away from a commitment to length of life to embrace a concern for maintaining the highest quality of life and relief of suffering that is possible. The Health Care Decisions Act in the Virginia Code clearly recognizes that palliative support is to be provided for terminally ill patients, even in situations where the necessary dose of pain medications may be in excess of normal prescribing guidelines. From an ethical perspective, we take this to imply that once the highest priority has been placed on pain relief, it is reasonable to accept that death may no longer be forestalled.
    
3. We recommend that while the facility should be responsive to a patient’s requests to eat (i.e. PO intake should not be restricted if the patient indicates a desire to eat), we do not have an obligation in the case of a terminally ill individual to make an effort to increase the patient’s appetite. Since the highest priority in such cases is to maintain comfort, we do not believe that the side effect of appetite suppression constitutes a serious moral problem when increasing pain medication is necessary to relieve discomfort. The attending physician and the facility have already agreed to avoid life-prolonging care for this individual by writing a DNR order and agreeing to honor the family’s refusal of a PEG tube. On the basis of this fact, the ethics committee recommends that the facility does not face an ethical problem in choosing to withhold clinical interventions that would serve only to prolong the dying process. There has been no ethical debate in this case concerning the justification for withholding life-prolonging care. We recommend that taking steps to maintain or increase appetite can be considered the provision of life-prolonging care, and can certainly be avoided when such efforts are accompanied by increased discomfort.
    
4. In summation, we recommend that, based on the attending physician’s and family’s agreement that life-prolonging care can ethically be withheld in this case, it is not morally problematic for staff to act consistently with the family’s wishes to provide palliative support for Mr. A, even if the provision of that care may allow the patient to deteriorate secondary to poor nutritional intake. So long as the patient is not being denied food that he requests, we view the loss of appetite as a normal part of the dying process that can be tolerated. We also recognize an obligation to provide effective pain relieving care, and recommend that highest priority should be placed on palliative support once it has been determined that death is imminent. In short, we do not believe that the attending physician would be acting unethically by choosing to meet Mr. A’s pain needs, even if that makes it more difficult to meet his nutritional needs.

Discussion:
The most important information about this case, from an ethical perspective, is the unanimous agreement that Mr. A is terminally ill and that it is acceptable to withhold life-prolonging care such as enteral feeding. This patient suffers from a serious infection that is not likely to respond to antibiotics, and he is not a candidate for surgical intervention. In fact, the consulting surgeon recommended not only that surgery is contraindicated, but that the most reasonable course of action for this patient would involve withholding ALL life prolonging care including further use of antibiotics.

Since there is no clinical doubt about Mr. A’s prognosis, question has developed surrounding the use of pain management medications. Mr. A has been receiving palliative support, but his pain is significant and difficult to control. According to the attending, better control of Mr. A’s pain would require doses of pain medications that would result in an even more obtunded state than Mr. A now experiences. If the patient were sedated to that level, then he would be likely to eat less regularly and would be at risk of complications stemming from insufficient nutrition. This outcome would not be uncomfortable for the patient, as he would be receiving ample pain meds, but it would allow death to come earlier rather than later. The question in this case surrounds the ethical implications of allowing this course of action.

The Ethics Committee believes that the ethical question posed by this case is serious, but that it has already been answered. We have already agreed to forego treatments that could be considered “life-prolonging”. Mr. A has an active DNR order, and enteral feeding has been withheld. We have already accepted that death will come sooner rather than later for this patient, and we recommend that such a recognition supports the increase in palliative support. Since the attending physician and members of the ID team have already accepted that life-prolonging care can be withheld, we must shift our thinking away from saving this patient’s life, and concentrate more on providing a comfortable existence until the patient expires. We recommend that a shift in thinking toward a more “hospice” type view is reasonable in this case, and that there is no moral problem in dealing aggressively with Mr. A’s discomfort. We recommend that palliative support is our highest priority for Mr. A, and that allowing him to experience a natural anorexia is not unethical. Therefore, we would support a choice by the attending physician to increase pain medications for Mr. A so long as he believes that he is acting according to accepted medical standards of care, in the best interest of the patient, and with consent from the patient’s next of kin.

This report is a non-binding recommendation only, and discusses only the ethical aspects of this case. This report does not take the place of consultation with other committees or individuals in distinct areas of expertise. If further discussion would be helpful, the ethics committee is available for additional consultation.

Date _______________________