Betsy does not enter the clinical trial but does agree to surgery and receives radiation treatment for her back. She is sent home on analgesics for her pain but she is not well enough to manage the restaurant and hires the son of a friend to help Dani.
Three months later
Betsy has increasing back and pelvic pain. She becomes weaker, is nauseous and vomits, and is somewhat confused. She is readmitted. The teams of residents have changed on the ward and there is another resident assigned to Betsy’s case. He speaks to Elsi and Mado.
The medical staff agrees not to write a do not resuscitate (DNR) order on Betsy’s chart until Maxon can arrive to say goodbye to his mother. Betsy dies peacefully one week later, never having spoken of her illness with her family.
Do not resuscitate, medical futility and limits to treatment
There are no quizzes in this exercise. You are asked to think about the topic in the light of the case of the Exantus family and the suggested literature. Try to put yourself in the place of the physicians involved in the cases. Write down the following:
- Who are the stakeholders who need to be consulted or considered in your decision?
- What information from each would you like to have?
- If you had to explain your reasoning to an ethics committee, what arguments would you present?
Decision-making around the end of life is one of the most frequent and visible ethical dilemmas that health care workers face. Can patients or their families demand that everything possible be done? Must physicians accede to such requests if they disagree? On the other hand, can physicians or hospitals impose DNR or withdrawal of life-sustaining treatment?
How does this help us? We are not obliged to accede to such requests, indicating that we have some professional discretion in making a decision. But what information are we to use? What constitutes “benefit,” and to whom? How much benefit, or lack thereof, is contained in “almost certainly will not”? A 10 per cent probability, a 1 per cent, a 0.01 per cent? And is it our values and opinion as professionals that should take precedence or those of the patient and/or surrogate?
Consider the following scenarios and decide what you would do using the information and arguments you have written down:
- An 85 year old man with chronic obstructive pulmonary disease and dementia, who resides in a nursing home, collapses while at lunch. The nursing home staff start cardiopulmonary resuscitation (CPR) and call an ambulance. CPR continues for the 15 minutes it takes to arrive at the emergency room. Does the emergency room staff continue the CPR? Why or why not?
- A 32 year old mother of three is burned in a house fire and is admitted to the burn unit with third degree burns over 80 per cent of her body. The unit staff knows that probability of survival in such cases is less than 10 per cent, and with considerable suffering. They have a policy to palliate such patients with pain medication until “inevitable” death. Is this policy a) morally, b) legally defensible?
- Dr. Harrell says that a DNR order will be placed on Betsy’s chart and states that the physicians will not do anything that would “prolong her death.” Is this an acceptable course of action, either morally or legally?
- A comatose patient with multi-organ failure has been in the intensive care unit on life support for two months, and the staff feels that there is no chance of recovery. The family refuses to agree to withdrawal of life support, citing religious beliefs. After protracted discussions with the family, the hospital seeks a court order allowing them to terminate treatment. Is this an acceptable course of action? Is there a difference between withholding and withdrawing treatment?
In thinking about these issues, consider the policy guidelines for end of life care and DNR in your province or territory. If you are working in a hospital, does it have guidelines? This article will help in formulating your reasoning: “When is medical treatment futile?” by D.L. Kasman.