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Current Legal and Ethical Controversies in American Health Care

Current Legal and Ethical Controversies in American Health Care. Medical Planning and Care at a Time of Advanced, Irreversible Illness. Instructors. Marshall B. Kapp, J.D., M.P.H. Kenneth Brummel-Smith, M.D. Charlotte Edwards Maguire Professor, Department of Geriatrics. Case 1.

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Current Legal and Ethical Controversies in American Health Care

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  1. Current Legal and Ethical Controversies in American Health Care Medical Planning and Care at a Time of Advanced, Irreversible Illness

  2. Instructors • Marshall B. Kapp, J.D., M.P.H. • Kenneth Brummel-Smith, M.D. Charlotte Edwards Maguire Professor, Department of Geriatrics

  3. Case 1 • Mrs. C, 75-year-old widow • Severe emphysema • Found unresponsive at home • EMS performed endotracheal intubation and resuscitated her. • Admitted to hospital and treated for respiratory failure and pneumonia, now lucid and able to communicate

  4. But, cannot be weaned from the respirator • After several weeks, Mrs. C wants the respirator removed. • No advance directive or prior discussions • ??

  5. Case 2 • Mr. V, 86-year-old man • Advanced dementia • Sectarian nursing home • At a certain point, stopped eating and put on NG tube • Bedridden, incontinent, lies in nearly fetal position, in apparent distress, pulling at feeding tubes

  6. Wrist restraints • Several comorbidities

  7. Only relative is cousin, who wants feeding tube discontinued. • Years earlier, Mr. V said, “If I ever become senile like my neighbor, please shoot me.” • NH refuses, citing religious beliefs • Physician refuses to “starve” Mr. V to death

  8. Case 2 A • Same as Case 2, except Mr. V is a 26-year-old man with severe traumatic brain injury suffered in a motorcycle accident?

  9. Case 3 • Ms. M., 88-year-old widow • NH resident for 2 years • Moderate dementia, confused but some interaction with other residents and in generally good physical health

  10. Only relative is a son to whom she gave durable power of attorney (DPOA) when Ms. M entered the NH. • NH notified son that Ms. M developed a bad tooth abscess and requested consent to have her treated by a dentist.

  11. Son refused. “Mom has lived a good, long life. At this point, she shouldn’t be burdened with a bunch of people poking and prodding her.”

  12. Case 4 • Ms. L, 85-year-old widow with dementia • Admitted to NH from hospital 2 years ago. Hospitalized for hip fracture incurred in auto accident while still driving. Prior, lived in apt. with her sister. • Chronic lymphocytic leukemia and hypertension now

  13. Did OK in NH, but progressively more severe dementia. • Paces, talks to herself. • Periodic blood transfusions to control leukemia, does not understand and sometimes resists. Necessary to sedate and restrain her during transfusion.

  14. 2 years before car accident, Ms. L executed advance directives: • DPOA naming sister as agent • Living will—”…I do not want medical interventions that prolong my life if I have an incurable or irreversible medical problem that is not terminal, but which inflicts upon me severe or progressive physical and/or mental deterioration and loss of ability to function normally.”

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