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CASES

This case study explores the ethical dilemmas faced by Dr. Morrow in treating Mr. Carlson, a terminally ill patient with diffuse lymphoma, focusing on advance directives, Quality of Life, and end-of-life care decisions.

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CASES

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  1. CASES FINDING THE KEY

  2. MR. CARLSON I[ADVANCE DIRECTIVES] • Mr. Carlson is 73 years old and has been diagnosed with lymphoma. He received one course of chemotherapy but was told that even with another course of chemotherapy the best he could hope for was another 6 months to live. • IS MR. CARLSON TERMINALLY ILL? • WHAT MATTERS SHOULD BE CONSIDERED IN THE DECISION ABOUT ANOTHER COURSE OF CHEMOTHERAPY? • WHAT SHOULD THE DOCTOR BE TALKING ABOUT WITH HIM AT THIS POINT? • WOULD YOU CONSIDER ANOTHER COURSE OF CHEMOTHERAPY FUTILE?

  3. MR. CARLSON II • He had been living alone in Reno but decided to move to Cleveland to live out his days with his niece who is his only relative. • WHAT DOES THIS MOVE TELL YOU ABOUT MR. CARLSON’S DEATHSTYLE? • WHAT SHOULD MR. CARLSON AND HIS NIECE BE TALKING ABOUT AT THIS TIME?

  4. MR. CARLSON III • After settling in his new home he began to suffer from congestive heart failure and went to Dr. Morrow, a local oncologist for help. • HOW SHOULD DR. MORROW APPROACH HIS CLINICAL ENCOUNTER WITH MR. CARLSON? • WHAT SHOULD DR. MORROW ATTEMPT TO LEARN ABOUT MR. CARLSON? • WHAT SHOULD MR. CARLSON ATTEMPT TO LEARN ABOUT DR. MORROW?

  5. MR. CARLSON IV • Dr. Morrow ordered hospitalization and Mr. Carlson agreed but insisted that he be made DNR upon admission. His niece agreed with his request and presented Dr. Morrow with a copy of her uncle's living will and Durable Power of Attorney for Healthcare (appointing her as the attorney-in-fact) which he had signed in Nevada. • IS IT APPROPRIATE FOR MR. CARLSON TO “INSIST” ON BEING DNR? • WHAT SHOULD BE DR. MORROW’S REACTION TO MR. CARLSON’S DECISION? • SHOULD DR. MORROW CONSIDER CPR FUTILE? • HOW SHOULD THE DNR COMFORT CARE LAW IN OHIO PLAY OUT IN THIS SITUATION? • IS A NEVADA ADVANCE DIRECTIVE VALID IN OHIO?

  6. MR. CARLSON V • However, Dr. Morrow talked Mr. Carlson into being a full code "for a while" so his situation could be assessed. • IS IT APPROPRIATE FOR DR. MORROW TO PERSUADE MR. CARLSON TO BE A FULL CODE? • SHOULD DR. MORROW BE MORE SPECIFIC THAN “FOR A WHILE?” • IS DR. MORROW TAKING ADVANTAGE OF MR. CARLSON’S VULNERABILITY? • IS AN ASSESSMENT NECESSARY? • DOES MR. CARLSON HAVE TO BE A FULL CODE FOR THE ASSESSMENT TO BE DONE?

  7. MR. CARLSON VI • After three days Mr. Carlson arrested and he was resuscitated and placed on a ventilator. His niece requested again that he be made DNR. • WHAT SHOULD DR. MORROW DO NOW? • WHAT ETHICAL PRINCIPLE SHOULD DR. MORROW BE FOLLOWING IN ADDRESSING MR. CARLSON’S SITUATION? • WHAT ABOUT THE OHIO DNR COMFORT CARE LAW NOW? • IS MR. CARLSON’S CARE NOW FUTILE? • WHAT IS THE FORCE OF THE ADVANCE DIRECTIVE AT THIS POINT? • WHAT AUTHORITY DOES THE NIECE HAVE?

  8. MR. CARLSON VII • A neurological consult revealed that his EEG was so bad that, even if he could be weaned from the ventilator, his mental status would be highly impaired. • IS QUALITY OF LIFE AN ISSUE HERE? • DID MR. CARLSON’S VALUE DECISIONS COVER THIS SORT OF SITUATION? • WHAT KIND OF FUTILITY DECISION SHOULD BE MADE NOW? • HOW COULD MR. CARLSON’S ADVANCE DIRECTIVE HAVE HELPED IN THIS SITUATION?

  9. MR. CARLSON VIII • Dr. Morrow still refused to make him DNR and the next day when his kidneys suddenly ceased functioning Mr. Carlson was sent for dialysis without the consent of his niece. • SHOULD MR. CARLSON HAVE BEEN SENT FOR DIALYSIS? • SHOULD DR. MORROW HAVE SECURED THE CONSENT OF MR. CARLSON’S NIECE BEFORE SENDING HIM TO DIALYSIS? • IS MR. CARLSON RECEIVING FUTILE TREATMENT NOW?

  10. MR. CARLSON IX • While receiving dialysis his blood pressure bottomed out and he was given vasopressors to restore it. Another neurological consult revealed an even more compromised EEG which indicated that he had a 93% chance of being vegetative and a 7% chance of severe mental impairment with 0% chance of returning to his previous level of functioning. • WHAT SHOULD DR. MORROW DO NOW? • WHAT SHOULD MR. CARLSON’S NIECE DO NOW? • WHAT IS THE FORCE OF THE ADVANCE DIRECTIVE AT THIS POINT? • DO YOU THINK DR. MORROW WOULD/SHOULD ADMIT TO THE FUTILITY OF TREATMENT NOW?

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