Final Case study

PHI 324 – Case Study The Case of Mrs. M Mrs. M was a 54 year-old woman who was transferred to a tertiary care hospital's critical care unit from a community hospital. She had been diagnosed with an acute anterior wall myocardial infarction (heart attack). Secondary diagnoses were acute pancreatitis, disseminated intravascular coagulation, acute respiratory failure, and lactic acidosis. She was placed on a ventilator. Due to medication and her serious medical problems, she was only periodically alert, but responsive when directly addressed. There were no written advance directives. She was hospitalized in 1990 for acute pancreatitis. She also had a history of anxiety and depression, which were treated by Haldol and Prozac for several years. She had attempted suicide about 10 years ago. Her husband and daughter (Martha), were supportive. A son was kept out of the decision-making process because of a history of depression and the fear that he may harm himself. Mr. M and Martha voiced agreement that Mrs. M should make her own decision regarding treatment or withdrawal from the ventilator. Mr. M said his wife had spoken about potential end-of-life situations. She was clear that she did not want to be kept alive if the quality of her life would be more compromised than it already was. For the first three days of hospitalization she was aware and responsive. She was presented with the possibility of pancreatic surgery to relieve her from the terrible pain she was experiencing, and told that the surgery was high risk with a 50 percent chance she could die in surgery. Recovery would require extensive respiratory care, which meant time in an extended care facility. She was also informed that she now required dialysis. She declined the surgery and dialysis expressing a desire to be withdrawn from the ventilator. The physician agreed to her request, which had the support of Mr. M and Martha. On the fourth day of hospitalization, the doctor had a conversation with Martha and hesitated on withdrawing the ventilator. He called for an ethics committee consult. He became concerned about Mrs. M's age and potential to rally medically. He was also concerned about her past history of depression, and wondered whether she desired a kind of physician-assisted suicide. He also began to question her competence and/or decision- making capacity. Mr. M and Martha were angered at this decision-making reversal and the consult with the ethics committee. They had told Mrs. M that her decision would be honored and they were in the process of already struggling with the grief that would be inevitable. Such ambivalence caused even more conflict and anxiety. (Adapted from Kuczewski, M. & Pinkus, R. An Ethics Case Book for Hospitals: Practical Approaches to Everyday Cases. Washington D.C.: Georgetown University Press, 1999)