CASES

1. CASES FINDING THE KEY

2. BOBBY C. I[ECONOMIC CONSIDERATIONS] • Bobby C. is now six months old. He was born prematurely with a birth weight of 800 grams and had multiple problems from the beginning. • HOW SHOULD WE THINK ABOUT THE CHANCES OF SURVIVAL FOR LOW BIRTH-WEIGHT INFANTS? • IS THERE A LOW BIRTH-WEIGHT THRESHOLD? • IS IT EVER APPROPRIATE TO TALK ABOUT FUTILE CARE FOR INFANTS?

3. BOBBY C. II • Bobby developed hyaline membrane disease due to his underdeveloped lungs and the need for a respirator. He also developed rickets. A CAT scan revealed some calcium deposits in the brain that might or might not compromise his mental functions. He is also microcephalic. Within the first month, Bobby developed thrombocytopenia (low platelet count) for which he was given transfusions. He now suffers from a depression of his immunological system, indicating HIV/AIDS related to the transfusions. He shows little interest in eating, and all attempts to bottle-feed him have failed after a couple of days. • IS BOBBY SUFFERING FROM MULTIPLE SYSTEM FAILURE? • CAN ANY OF THESE PROBLEMS BE REVERSED? • IS BOBBY IN “TERMINAL” DANGER? • SHOULD THE PHYSICIANS BE HAVING A DISCUSSION WITH HIS PARENTS ABOUT FUTILE TREATMENTS?

4. BOBBY C. III • His healthcare costs are being supported by Medicaid, and they are estimated to be in the neighborhood of $850,000 for his six months of hospitalization. • IS THIS A REASONABLE AMOUNT TO PAY FOR 6 MONTHS OF LIFE WITH THIS OUTCOME? • DOES IT LOOK LIKE THE HIGH COST OF HIS CARE WILL CONTINUE? • SHOULD RESOURCE ALLOCATION BE CONSIDERED IN THIS CASE? • HOW SHOULD RESOURCE ALLOCATION BE WEIGHED AGAINST POSSIBLE OUTCOMES OF FUTILE CARE?

5. BOBBY C. IV • Now the healthcare staff, the attending physician, and his parents are considering the possibility of a bone marrow transplant to deal with the thrombocytopenia and the immunosuppression. The chances of success in an infant this small are minimal, and the procedure is largely experimental in infants having this condition. • IS THE BONE MARROW TRANSPLANT FUTILE CARE? • IF THE TRANSPLANT WERE SUCCESSFUL , HOW WOULD HIS OTHER PROBLEMS BE AFFECTED? • ARE THERE LIMITS TO AGGRESSIVE INTERVENTIONS WHEN CARING FOR NEWBORNS? • IS THERE A LIMIT TO THE AMOUNT OF MONEY THAT SHOULD BE SPENT ON ANYONE WHEN ALL INDICATIONS ARE THAT THE CARE IS FUTILE?

6. BOBBY C. V • If the transplant is successful, it will only alleviate one of his many problems. • WHAT DO YOU THINK OF BOBBY’S QUALITY OF LIFE? • COMPROMISED MENTAL FUNCTION • CALCIUM DEPOSITS • MICROCEPHALY • BONE DEFORMITIES • FAILURE TO THRIVE • HIV/AIDS

7. BOBBY C. VI • The parents want to authorize the transplant because they think his condition is a punishment from God because they were seriously considering aborting Bobby early in Ms. C.'s pregnancy. • DO THE PARENTS HAVE ENOUGH INFORMATION IN THIS CASE? • WHAT ROLE SHOULD MEDICAL UNCERTAINTIES AND PROBABLITIES PLAY IN THE CONVERSATIONS WITH THE PARENTS ABOUT FUTILE CARE? • ARE THE PARENTS’ BELIEFS ABOUT “PUNISHMENT” EXERCISING A COERCIVE INFLUENCE ON THEIR CONSENT? • SHOULD THE PARENTS’ BELIEFS BE HONORED EVEN THOUGH THE TREATMENT MIGHT BE FUTILE?