CASES

1. CASES FINDING THE KEY

2. MR. BARTLING I[VALUES] • William Bartling was 70 years old when he entered Glendale Adventist Hospital in California in 1984. He entered the hospital for treatment of depression. At the time of his admission he was known to be suffering from emphysema and arteriosclerosis. At the time of his admission a routine physical examination revealed a tumor on his lung and a biopsy confirmed that it was malignant. The biopsy needle caused the lung to collapse and the emphysema prevented the lung from reinflating causing chronic respiratory failure. He was placed on a ventilator with a tracheotomy. In addition Mr. Bartling had an abdominal aneurysm. Although each of these conditions could individually be lethal, he was not diagnosed as terminally ill. Attempts to wean him from the ventilator were unsuccessful and he was considered to be ventilator dependent. His physicians admitted that, at best, he could only live for a year if he could be weaned from the ventilator. • IS MR BARTLING TERMINALLY ILL? • WHAT FEATURES OF HIS CONDITION WOULD LEAD YOU TO YOUR CONCLUSION?

3. MR. BARTLING II • Initially Mr. Bartling attempted to remove the ventilator tubes but was unsuccessful. To prevent a successful attempt, he was placed in restraints so that the tubes could remain in place. Both Mr. Bartling and his wife asked the physicians to remove the ventilator but they refused. • SHOULD MR. BARTLING’S ATTEMPT TO REMOVE THE VENTILATOR TUBES BE SEEN AS HIS JUDGMENT ABOUT THE FUTILITY OF HIS TREATMENT AND AN EXERCISE OF HIS RIGHT TO REFUSE TREATMENT? • WAS IT ETHICALLY CORRECT TO PLACE MR. BARTILING IN RESTRAINTS? • WERE THE PHYSICIANS CORRECT IN REFUSING TO REMOVE THE VENTILATOR?

4. MR. BARTLING III • Mr. and Mrs. Bartling then filed a complaint against Glendale Adventist Hospital seeking damages for battery and the violation of Mr. Bartling's constitutional rights both state and federal. As a part of the complaint, there was attached a living will executed by Mr. Bartling and his appointment of Mrs. Bartling as his attorney-in-fact in a Durable Power of Attorney for Healthcare. In the documents Mr. Bartling expressed a clear understanding of his healthcare condition, the distress he was in as a result of the continued ventilator support, the consequences (which could result in death) of the removal of the ventilator, and his unswerving desire to have the ventilator disconnected. • ARE MR. BARTLING’S VALUES CLEAR ABOUT THE FUTILITY OF HIS TREATMENT? • DID THE HOSPITAL COMMIT BATTERY AGAINST MR. BARTLING? • WHAT AUTHORITY SHOULD ATTACH TO THE ADVANCE DIRECTIVE IN THIS CASE? • DOES THE ADVANCE DIRECTIVE SEEM CONVINCING?

5. MR. BARTLING IV • His wife and daughter added documents which released the hospital and his physicians from all civil liability for whatever consequences might result from following his wishes. The hospital and his physicians remained steadfast in their refusal to disconnect the ventilator both because he was not considered terminally ill and because, so they contended, the religious traditions of the hospital required that life be preserved as long as the patient had cognition, even with such a poor quality and prognosis. • HAVE HIS WIFE AND DAUGHTER PROTECTED THE HOSPITAL? • WHAT DO YOU MAKE OF THE PHYSICIAN’S REFUSAL TO CONSIDER MR. BARTLING TERMINALLY ILL? • SHOULD THE RELIGIOUS COMMITMENTS (VALUES) OF THE HOSPITAL DICTATE THE PATIENT’S CARE? • HOW SHOULD QUALITY OF LIFE CONSIDERATIONS ENTER INTO THESE CLINICAL DECISIONS?

6. MR. BARTLING V • The situation was complicated by the apparent vacillation of Mr.. Bartling in his decisions. He said that he did not want to die but neither did he want to live on a ventilator. However, at times he seemed to be reconciled to his impending death. On the infrequent occasions when the tubes became accidentally disconnected he seemed to gesture to the nurses to reconnect them. Finally, there were reports by some of the physicians that Mr. Bartling had said that he did not want the ventilator disconnected. • WHAT DO YOU MAKE OF HIS GESTURES TO RECONNECT THE VENTILATOR? • SHOULD MR. BARTLING BE CONSIDERED TO BE LACKING DECISIONAL CAPACITY? • WHAT DO YOU MAKE OF THE APPARENT RECONCILIATION WITH HIS DEATH? • HOW WOULD YOU HELP HIM CLARIFY HIS VALUES SO THEY ARE CONSISTENT REGARDING THE FUTILITY OF HIS TREATMENT?