By Ryan Pferdehirt, D.Bioethics, HEC-C

January 2021

Patient Decision-Making Bioethics Case Study

Sarah is a 73-year-old individual who identifies as female and is suffering from metastatic colon cancer. While an inpatient, she is cared for by her longtime oncologist, hospitalists, and ultimately a critical care team. Initially Sarah has decision-making capacity, Sarah makes decisions with her family (husband and two adult children).

When discussing treatment options and goals of care, Sarah inconsistently makes decisions based on who is present in the room. When the patient is by herself, she says that she knows she is very sick and is tired; and at this point, all she cares about is being comfortable. But when her family, particularly her husband, is in the room, Sarah will default to saying that she wants to “continue to fight.”

Multiple physicians have noticed the difference between what their patient says in private and when family is present. Family discussion centers on those militaristic notions of “fighting” the cancer. “Mom, you don’t want to give up, do you?” and “Let’s just keep fighting a little more, Honey.” Then when Sarah is alone with her providers, she says, “I really just want to make sure that I am comfortable and not in pain.” During the night shift, Sarah coded and was resuscitated per her Full Code status. She was transferred to the Medical ICU and seems now to have more pain and discomfort than previously. Her decisional capacity is unclear, and transient at best due to sedation and possibly anoxic injury. A family meeting is scheduled to discuss decisions to be made, including code status going forward.

ICU physicians, residents in particular, state a perspective that attempting resuscitation again would be “futile” and it is time to move to comfort measures only. The attending oncologist believes that it is too early to stop aggressive treatment and “withdraw care.” She wants to keep Sarah Full Code and obtain consent for at least another round of chemotherapy.

Both teams have requested that Ethics join the family meeting.