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END OF LIFE CARE / ADVANCE DIRECTIVES


The Case of Ginger: Autism and Blood Cancer Treatments

A 30-year-old woman, “Ginger,” is in the clinic, having been diagnosed several years ago with myelodysplastic syndrome (MDS, a blood disorder). There is a high chance that the disease will progress to acute myeloid leukemia (AML), with lower chance of survival, so physicians had started chemotherapy. This leads to other treatment decisions and dilemmas which become ethically complex.

 

 

Case Studies - Good Death or Assisted Suicide

Mr. Perry wants doctors to turn off his pacemaker. Would doing so respect Mr. Perry’s rights and autonomy? Or, would it be physician-assisted suicide?

 

 

Case Studies - Helping the Care Team Help Patient Patti

Patti, a 52-year old woman with history of asthma, chronic obstructive pulmonary disease, hepatitis C and substance abuse, presented to the emergency department after cardiac arrest at home with subsequent return of spontaneous circulation. When Patti’s husband didn’t respond to attempts to contact him, with no advance directive, it was deemed more helpful to support the care team’s communication efforts and to provide an ethics perspective with procedural recommendations and “what if” options.

 

 

Case Study - Why Are They Doing All This

Grace H. is a retired teacher who is suffering from Alzheimer dementia, who lives in a nursing home. She has not been feeling well lately. Her brother gives consent for her to be transferred to a hospital to discover what is going on, but after they have run a lot of tests, he asks, "Why are they doing all this?"

 

 

Case Studies - Managing Pain is a Family Affair

Mrs. W is a sixty-year-old African American woman with a recent diagnosis of breast cancer with metastases to the bone and lung. She has been married thirty-two years and has three adult children. Over the last month, she has experienced increasing pain that has not been effectively controlled by her physician. She has now been referred to hospice, primarily to get her pain under control.

 

 

Case Studies - My Patient’s Dying

I had never seen it before. I had no experience on which to base my unsettling suspicions. And yet, it was unmistakable. My patient, Ms. P, was dying right in front of me.

 

 

Case Studies - Opposition to Organ Donation

JD is a 25-year-old patient who sustained massive head trauma and neurological injury in a motorcycle accident. He is not brain dead, but after 4 weeks in MICU and several neuro consults, the prognosis for “meaningful recovery” is said to be less than 1%. JD has not regained consciousness and is apt to remain permanently in a vegetative state.

 

 

Case Studies - A Family Divided

A forty-five-year-old man with a three-year history of cardiovascular disease has entered the hospital with a stroke that has paralyzed his right side and caused him to aspirate food of any consistency. His mental status is clouded and there is disagreement as to whether he has decisional capacity. His language capacity is only “yes” and “no,” and his responses are inconsistent.

 

 

Case Studies - Mr. Jay's Case

The doctor explained that for Mr. Jay attempting resuscitation following a pulmonary arrest was not likely to succeed. The doctor further explained that even if resuscitation restarted his lungs, Mr. Jay would require aggressive care in an intensive care unit. Given these prospects, Mr. Jay told his doctor he would prefer that resuscitation not even be attempted.

 

 

Case Studies - Alice's Frail Mother

Alice watched her mother’s long slide into Alzheimer’s type dementia, certain that her mother’s careful attention to advance care planning would be able to prevent her worst nightmares.

 

 

Case Studies - Barney Says No

Almeda’s nurses and attending physicians want her long-time friend Barney to help them determine the direction her treatment should take now that she needs dialysis. She’s already on a ventilator, a feeding tube, and receiving high doses of antibiotics. She would be better, Barney thinks, if she could watch TV a little.

 

 

Case Study - DNR for an Adult with Down Syndrome

George is a 23-year-old man who has Down's syndrome. He is in an accident in which he sustains a severe brain injury is and shows no signs of consciousness. In order to withdraw life-sustaining treatment, his parents must present convincing evidence. George did not state his wishes in an advance directive.

 

 

Case Study - The Role of Literacy in Making Wishes Known

A large number of Americans are more oral than literate. This paper details the ingredients of a traditional oral morality capable of engaging biomedical issues and indigenous to people who think in proverbs, stories, and relationships.

 

 

Case Study - I Paint

A narrative about illness, coping, societal norms, art and death.

 

 

Case Study - Who Should Talk to the Family

Omer was a 94-year-old widower who had lived independently for many years. He had always been eager to get health problems fixed, including the most recent issue, which required colon surgery. When Omer doesn't recover well, issues arise as the physicians do not speak directly with Omer's children.


CASES OF MORAL DISTRESS


Case Study - Nursing Staff in Moral Distress When Patient Wishes Not Followed

Freda is a 32-year-old lady living in a long-term care facility who is chronically ill with multiple sclerosis. She voices desires to die peacefully and not to have a feeding tube placed. She is taken by her mother to a neurologist and when she returns, she has a feeding tube. Read this case to see how nursing staff responded.

 

 

Case Study - Casey Last Inning

Nursing staff are reluctant to carry out CPR on a patient in a persistent vegetative state despite her mother's insistence and the physician's orders to do so.

 

 

Case Study - If you prick me do I not bleed 

A nurse experiences moral distress with being told to continue monitoring a 100-year-old patient's blood work as long as she remains on blood thinners.

 

 

Case Study - The Wanted Unwanted Doctor 

Mary Jo is diagnosed with bladder cancer but does not wish to have surgery. After refusing surgery twice, her doctor tells her that he cannot be her doctor any longer. This case discusses the dilemmas that occur when a patient does not heed the advice of a doctor, and what obligations do the patient and doctor have in maintaining the patient-doctor relationship.


CASES OF WITHDRAWING / WITHHOLDING CARE


 

Artificial Nutrition and Hydration

A 49-year-old male came into the cardiac care unit with an inferior wall myocardial infarction, and shortly thereafter coded. Resuscitation attempts succeeded; however, over the course of a few days he went into multi-system failures. This case study explores whether the provision of artificial nutrition and/or hydration is a medical treatment, and in what situations should artificial nutrition and/or hydration be offered?

 

 

Case Study - To Tube Feed or Not 

Jennie is a 79-year-old woman who had suffered from hypertension, diabetes and many strokes. She had an advance directive, which indicated that she did not desire any surgery, antibiotics, resuscitation or tube feeding. When it becomes very difficult for her to eat, requiring an aide for a couple of hours each meal, her daughter decides that it is appropriate for a feeding tube to be placed as Jennie does not have a fatal illness, just simply requires adequate nutrition.

 

 

Case Study - The Case of Karen Ann Quinlan 

Karen Ann Quinlan, a twenty-two-year-old who ingested a harmful mix of drugs and alcohol, suffered two fifteen-minute periods of interrupted breathing which left her in a chronic vegetative state without any cognitive functions. When the trial court refused the order to withdraw life-support, her father, who was her guardian, appealed.

 

Case Study - The Case of Claire Conroy 

An 84-year-old non-ambulatory nursing home patient was confined to semi-fetal condition with "sever organic brain syndrome." With chronic, non-healing ulcers, bowel incontinence, and very limited conscious movement, her nephew requested removal of her nasogastric tube. Her physician declines, and the courts are involved.

 

 

Case Study - The Case of Nancy Cruzan 

A 30-year-old accident victim suffered lack of oxygen to her brain for six to twenty minutes. She was in a persistently comatose and vegetative state, sustained by a gastronomy feeding tube. What should happen to this patient when she is in a state of progressive spastic quadriplegia with irreversibly contracted extremities, but doctors say she could live another thirty years

 

 

Case Study - The Case of Helga Wanglie 

On December 14, 1989, Helga Wanglie, 86, fell in her Minneapolis home and broke her hip. After the fracture was successfully set, she was discharged to a nursing home. On January 1, 1990, she was readmitted due to developing respiratory failure and place on a respirator. During the next five months repeated attempts to wean Mrs. Wanglie from the respirator were unsuccessful; she was conscious, aware of her surroundings, and could recognize her family.

 

 

Case Study - Refusal to Eat in a Long Term Care Facility 

John is a 92-year-old who was recently admitted to a long-term care facility after being discharged from the hospital after a stay for pneumonia. He is nonverbally refusing meals, and with no obvious family members to relay his wishes, staff are finding it hard to determine what the next step should be in his care.

 

 

Case Study - Unprepared to Talk About Dying 

Pat is having a difficult time giving consent for the "Do Not Resuscitate" order for her 90-year-old father, because they never had a discussion about dying. This case raises questions about obstacles to open communication about death and goals of care.


ACCESS TO CARE / VULNERABLE POPULATIONS


The Case of Jesse, Unrepresented and Homeless

A 60-year-old homeless man, “Jesse”, is found confused and in distress by a passerby who calls 911. Paramedics bring the man to the hospital. Jesse’s feet and legs are swollen and covered in ulcers and dead tissue—diagnosed as osteomyelitis, or infection of his legs. His past medical history is established to include chronic obstructive pulmonary disease (COPD), chronic foot infections, alcoholism, and tobacco use. In addition to this, clinicians find a mass in Jesse’s lung that could either be TB or cancer. Physicians recommend a biopsy. The infections in this patient’s legs are so severe that a double amputation is recommended, also.

 

 

Case Studies - First My Daughter and Now This

Fiona’s twenty-two-year old daughter was killed in a car wreck. Fiona took custody of her two grandchildren and worked as a housekeeper in a private home while the children were in school. Fiona had no health insurance. She earns too little to buy an individual plan and too much to qualify for Medicaid. When she started bleeding, she just kept buying napkins to absorb the blood.

 

 

Case Studies - I Know What You’re Thinking

An African American male patient, age forty-two, was admitted to a skilled nursing unit after surgery for head and neck cancer with lymph involvement, newly diagnosed. Extensive excision of the tumor had been done, and the patient had a newly placed tracheostomy and feeding tube.

 

 

Case Studies - Walking The Tightrope

Providers and family members alike must tread carefully when caught between a patient’s crankiness and a family’s report that the patient’s pain is not being managed.

 

 

Case Study - Is More Better in Oncology 

A 44-year-old, divorced mother of two teenagers is diagnosed with metastatic breast cancer. The oncologist suggests that she undergo a rigorous treatment process that has probably mortality of 25%, limited efficacy and huge cost burden, which her insurance will not cover. She asks for an ethics review when the hospital will not approve the treatment without insurance coverage.

 

 

Case Study - Rejecting Doctors Orders 

Herman is a 55-year-old farmer with worsening, chronic back pain refuses surgery and states he will go to the local chiropractor, instead His doctor is faced with a dilemma. He does not feel he can contact the chiropractor, but feels that the manipulation could worsen Herman's injury.

 

 

Case Study - Sheila Shares Her Boyfriend’s Experience at the VA 

A patient's girlfriend discusses challenges and frustrations associated with receiving care from the Veterans Administration.

 

 

Case Study - Patient Vulnerability from a System Failure to Protect

With a Medicare policy change, Teresa's home health agency will no longer be able to provide her care. Her husband and sister are unable to provide the high acuity assistance she needs. What is each person's responsibility when it comes to vulnerable patients who are not protected by the system

 

 

Case Study - The Case of Immigrant Populations 

Delivering health care to non-English speaking immigrant populations requires knowledge and appreciation of the patient's culture. Acquiring the skills to bride the two worlds calls for self-awareness by the practitioner and a commitment to cultural competence by the organization.

 

 

Case Study - Adults with Disabilities as Essential Partners in Their Healthcare 

The case of Russell discusses challenges in healthcare for people with disabilities, and how people with disabilities can be active participants in their care. Are people more alike than they are different?


CONFIDENTIALITY


Case Study - What are the Limits of Community Right to Know 

Jack is a hard-working employee at your restaurant in a small, rural town a few hours from the nearest big city. He has been missing work for medical treatments outside of town and has recently started to show signs of losing weight and having a cold all the time. Members of the community look to you for news regarding Jack's health. How do you handle the situation when Jack's health begins to negatively affect your business?

 

 

Case Study - Confidentiality of a Diagnosis 

Megan and Ken have been married for 22 years, but unhappily. They do not sleep in the same room and are planning to divorce after their children move. Megan asks for Ken to drive her to a procedure that would determine whether or not she has cancer, but she is distraught after the physician gives the biopsy results to Ken instead of her.


MISTAKES IN MEDICINE


Case Studies - One Small Cut that Killed

One day, a patient comes to see her complaining of ankle pain on his right leg. The patient is a farmer and says that he fell while he was taking care of his chickens in the chicken coup. He has some cuts and bruises on either leg, complains of a swollen right ankle, but appears to be fine otherwise. Dr. Contadina instructs him to purchase an air cast at a pharmacy along with some ibuprofen and to take it easy.

 

 

Case Studies - Could This Happen At Our Hospital?

What should physicians and families do when the patient they are attending is in the dying process? The answer may not be easily categorized, but one thing is certain: the failure to communicate will always have grave consequences.


MATERNOFETAL MEDICINE


Case Studies - Our Pregnant Daughter Didn’t Want This

Twenty-nine-year-old Janet and her husband Jack were driving home from her ob-gyn appointment when tragedy struck. Another driver, elderly and distracted by an incoming text message, ran a red light and T-boned Janet and Jack’s Mini-Cooper. Both young people sustained severe injuries.

 

 

Case Studies - Abortion Rights and/or Wrongs

Kate is a 17-year-old patient, unmarried and 8 weeks pregnant. She is a rather remarkable girl in that she lives independently while still a senior in a high school. She tells you that she was an adoptee given back to foster care and then abused in that system.

 

 

Case Study - The Case of Angela C 

Angela C. was a 28-year old married woman who was approximately twenty-six weeks pregnant. She had suffered from cancer since she was thirteen-years-old but had been in remission for approximately two years before she became pregnant. The pregnancy was planned, and she very much looked forward to the birth. Her health seemed reasonably good until about the twenty-fifth week of pregnancy, when a tumor was found in her lung.

 

 

Case Study - Ethical Indicators of Futility in Critically Ill New Mother 

Melinda signed an advance directive that she wants to stay alive, if possible, but her husband, Matt is to make her decisions if she is unable. After the emergency c-section delivery of their newborn son, Melinda is in a coma, and Matt is left with the decision of whether or not to honor her wishes.


PEDIATRIC MEDICINE


Case Studies - A Sister For Joshua

There are such emotional overtones to this case that it might be helpful to use Immanuel Kant’s recommendation: What if everybody performed the action with the same purpose in mind?

 

 

Case Study - The Case of a 22-Month-Old Boy 

A twenty-month old Puerto-Rican boy is brought to the clinic by his mother who believes he has a folk gastrointestinal illness, called empacho. His mother has been out of work with a back injury and lacks support, and the child has no signs of pathological illness. This case involves discussion of the importance of diversity and the value of cultural/religious healing.

 

 

Case Study - Clinical Research Involving Children 

TJ is a 7-year-old boy who has had moderately severe asthma since the age of three. He is eligible to be in a clinical research trial of a new asthma medication. This case addresses the ethical issues which surround clinical trials that involve children.

 

 

Case Study - The Case of Baby K 

Baby K is an infant female born with anencephaly. Permanently unconscious, she has only brain stem function. During the initial hospital stay, hospital personnel "urged" the mother to permit a DNR order, but she insisted on the use of the ventilator. When a therapy is "futile" how much power should the mother have to demand the treatment?

 

 

Case Study - A Minor Requiring Blood Products 

A 16-year-old male member of Jehovah's Witnesses incurred injuries in an auto accident. The injuries required surgery. He had informed both ambulance personnel and the hospital of his wish not to receive blood transfusions. Surgery was performed without the use of blood transfusions, but his blood levels continued to fall. This case deals with guardianship and religious ethics in minors.

 

 

Case Study - The Case of Sepsis in a Newborn

After an emergency c-section, Baby Girl X undergoes many surgeries to remove parts of her colon. When she subsequently gets sepsis and shock again, the parents are faced with the decision to continue aggressive treatment, leaving her to only receive nutrition by IV and possibly not live past about a decade, or to allow her to die naturally now.

 

 

Case Study - Out of Hospital DNRs for School Aged Children 

A twelve-year-old boy with terminal osteosarcoma on hospice, is reluctant to return to school after the school informed the family that his DNR request, which was signed by his physician, would not be honored at school.

 

 

Case Study - Conflicting Values in the Placement of Violent Teenager with Mental Disability 

When a foster home is not found for a 15-year-old girl, her state's Medicaid pays for her to be placed in a large mental facility in another state. When state policies change, the CEO and the case manager for the girl's managed care plan cannot agree on what should be the next step.


PSYCHIATRIC MEDICINE/DUTY TO WARN


Case Study - The Case of Tarasoff 

A misinterpreted kiss pushes a graduate student from India into an emotional spiral, resulting in murder. Who is held responsible when the student had warned his psychologist that he would kill the girl?

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