By Ryan Pferdehirt, D.Bioethics, HEC-C

August 2022

Bioethics case study on honoring patient wishes and end-of-life ethics.

Carson is a nurse at a long-term care facility. He is caring for Johnny, an 88-year old, male-identifying patient, with a history of chronic respiratory issues and mild dementia. While retaining sufficient decisional capacity, Johnny appointed his youngest daughter, Kristin, as DPOA for healthcare decisions. Additionally, Johnny has granted Carson—and the medical team— access to his advance care planning documents, which specify his wishes in the event he loses decisional capacity.

Over time, Carson has grown close to this patient. When there is time to do so, he watches television, listens to music, and even plays board games with Johnny. During these moments, they share stories, discuss current events, and tell jokes from their favorite comedians. Carson knows that Johnny’s deepest wish is to reconnect with his estranged daughter before he passes away. He tells Carson, “I know I’m not doing well and that my time here is limited. So, I want you to promise me that you’ll keep me alive long enough to touch my oldest daughter’s hand and say goodbye.” Carson shakes his hand, with every intention to keep this promise.

Weeks pass and Johnny’s condition worsens. He is suffering complications from pneumonia, resulting in organ failure and fluid build-up in the lungs. Per Johnny’s documented wishes, he remains at the LTC facility with no 911 calls for escalation to the hospital. Hospice workers come to coordinate his care, and it is anticipated that the patient may have only a few days before he passes.

Kristin, the DPOA daughter, and her siblings, know that their father wants to die a natural death. Everyone is on board with this plan. Carson is conflicted, however. He understands that Johnny’s advance directive is consistent with comfort measures and no prolongation of dying. Carson knows also that, more than anything, Johnny had wanted to reconcile with and say goodbye to his oldest daughter, Maria, who lives across the country. She had hesitated to come, and now says she is making arrangements to do so. But the earliest arrival would be a week or more.

Honoring Johnny’s final wish for family unification implies life interventions as needed to keep him alive a bit longer. Carson wholeheartedly believes the information he has from conversations with Johnny will or should make a difference to the care plan. So, he approaches Kristin, who promptly dismisses his concerns. She says, “No offense, but I think I know what my dad wants. He’s written it down and communicated it to me and my family. He wants to be comfortable. If my older sister gets here in time to say goodbye, that’s fine. If not, so be it. They were never that close anyway.” Johnny is no longer able to confirm or communicate his final wish to the rest of his family. And it had been verbal not written.

His nurse also had neglected to chart this conversation in the patient’s electronic medical record. There is no documentation that the conversation ever happened, despite a confirming handshake that Carson vividly recalls. As Johnny is dying on hospice care, Carson desperately wants to keep his promise to help prolong life until there is opportunity to allow an estranged older daughter to hold her father’s hand. The nurse acknowledges, however, that Kristin is the DPOA and that she is doing what her father had written in his advance directive. Carson is left with regrets.

What should be done?