27 Oct Case from Kuczewski’s Ethics casebook for hospitals

Case analysis part 1

Your case analysis will Include: 4 assessment areas:

medical indications (part 1)

patient preferences (part 1)

Segment 1 will include analysis of medical indications and patient preferences. Segment 1 should be no more than 3 page in length.

You may select any case from Kuczewski’s Ethics casebook for hospitals, with the exception of case 9 that I analyze extensively as an example for you. You may also use a case from a scholarly source such as the American Medical Association’s online ethics journal: Journal of Ethics | American Medical Association (ama-assn.org)Links to an external site.. Any case you select should have enough detail for your analysis to demonstrate your assessment for the 4 areas/topics and your problem solving skills.

 

 

 

I chose CASE 4 FOR MY ANALYSIS

 

 

 

 Case 4: “Please Don’t Cut Off My Leg” Going from a Wish to a Plan of Care

 

Key Terms: Autonomy, Surrogate Decision Making

 

Narrative Mr. R was a fifty-seven-year-old man with diabetes mellitus, hypertension, and severe peripheral vascular disease. Mr. R was morbidly obese, and his left leg manifested arteriole insufficiency for several years. The patient has now been admitted for a gangrenous left foot. He previously had surgery for revascularization, but this clearly had not been able to solve the long-term problem. The patient also has ulcers on his right foot. A course of intravenous (IV) antibiotics was begun to treat the infection. The attending physician sought a surgical consultation, and both physicians agreed that an amputation of the left leg below the knee was indicated. Both believed that the gangrene would eventually take the patient’s life unless the limb was amputated. They explained this to the patient, who simply refused. However, the patient’s responses to the physicians’ questions were not directly responsive and were somewhat irrational. For instance, he kept simply asserting that he did not want his leg cut off and that the physicians and everyone at the hospital were “racist.” Two of the patient’s adult brothers where present for this conversation and tried to interject to the patient that the doctors were “just trying to help him” and that he should “listen to them.” Nevertheless, no plan of care was able to be explored in any detail during this initial conversation. The surgeon and the attending physician said that they would come back the following day for a follow-up conversation. The attending physician paged the ethics consultant and asked that he also sit in on the meeting the next morning. During the next day’s conversation, the patient was more engaging of the prognosis. He clearly was fearful of having part of his leg removed; and at one point, in a low voice, he said, “Please don’t cut off my leg.” The attending physician explained that this was needed if the patient was to live for an extended period. Nevertheless, he also pointed out that the patient had a fair number of comorbidities and that the patient’s other foot could progress in the same way in the future. As a result, the ethics consultant who was present for this conversation suggested that the choice at this point might be better to focus on goals of care—for example, life extension versus palliation—rather than on particular interventions.

 

The Language and Issues of the Case This case in some ways is the most straightforward kind of informed consent case. The patient gets to be

 

informed of his options and make a decision. From the description of the patient, his decision-making capacity does not seem to be impaired. Nevertheless, 1. What will it mean for this patient to be adequately informed? That is, how can he come to appreciate what life postamputation would be like? And how could he come to appreciate what death from the gangrenous foot would be like with support from a hospice service? 2. What role does fear of the unknown—that is, life without one’s leg—play in this kind of decision? How can such fears be placed in proper perspective?

 

Perspectives and Key Points of View Mr. R: The patient had struggled with his health difficulties for a very long time. Although he was not depressed and wished to go on living, because there were a number of things that he enjoyed doing in daily life, he was terrified of starting to lose limbs to amputation. In particular, he was worried that the limited mobility that would follow would make him increasingly dependent on his family, especially if he ended up having both feet eventually amputated. The attending physician: The attending physician had seen many patients who had a below-knee amputation done owing to peripheral vascular disease. In general, he very much favored such a procedure, as it often resulted in a good quality of life for an extended period for his patients. However, in this case, he was more ambivalent because the patient’s medical problems would likely result in a continued diminishment of his quality of life. Thus, the physician hoped that the patient might begin to wrestle with the big picture of what he would want. The surgeon: The surgeon was surprised that there was much debate about what to do. He believed strongly in doing a below-knee amputation in this situation because it seemed to him that death from the progression of gangrene was a very undesirable way to die. The ethics consultant: The ethics consultant was initially concerned about the role that fear might be playing in the patient’s decision-making process. When he was told of the initial conversation with the patient, it seemed that the patient might “shut down” rather than engage the issues. The consultant hoped that they might be able to consider the long-term picture of what the patient’s life might be like after an amputation and what the patient might expect to happen thereafter.

 

What Actually Happened The discussion between the patient, the physicians, and the ethics consultant resulted in the patient tentatively deciding that he would like to pursue palliation rather than surgery. However, he wished to speak with a palliative care consultant and the hospice intake director. Mr. R wanted to get a clearer picture of how his discomfort would be managed and what his dying process would be like. He met with these persons the following day and was discharged to his home with hospice care within forty-eight hours.

 

 

 

 

 

 

Example

 

                  

 

                                  Medical Indications

                     Case 9 (2nd ed)/Case 6 (1st ed)

67 yo woman

 

 

Presenting problem/s (PP): Sepsis, probably caused by entero-bacteria passing through portions of the 

colon wall weakened by the CA

 

 

Medical history (Hx):

 Non-resectable (i.e., inoperable) colon cancer since 6 mo ago

 Recurrent episodes of sepsis

 

 

Signs/Symptoms (S/S) on admission:

 Generalized edema (swelling)

 Emaciated appearance/wasting

 Skin excoriations (abrasions)

 Paralysis of lower extremities; limited movement of upper extremities

 

 

Diagnoses (Dx):

 Sepsis 

 Colon CA

 “Spinal disease”

 

Characterization of condition(s):

 The colon CA is “terminal” in the general sense of causing death.

 The recurrent episodes of sepsis are critical and possibly end-stage terminal.

 

 

Initial goal(s) of care

Note: Goals of medical care should not be confused with patient preferences for care; the goals of care 

are what medicine could reasonably hope to accomplish in terms of benefit and avoidance of iatrogenic 

(i.e. health care caused) harms.

1. Providing relief and support near time of death 

2. Avoidance of harm to the patient in the course of care 

3. Education and counseling of patient re her condition and prognosis

Or

1. Prolongation of life

2. Maintenance of quality of life through relief of pain and suffering 

3. Maintenance of compromised status 

4. Education and counseling of patient and family re her condition and prognosis

 

 

 

 

 

After 3 days:

New Signs/Symptoms (S/S):

 Acute shortness of breath

 Acute GI bleed

 Lethargy

 Confusion

New Diagnosis (Dx):

 Either CHF (Congestive Heart Failure) or a PE (Pulmonary Embolism)

Note that “differential diagnosis” means that the diagnosis is either one or the other.

After transfer from the ICU to the step-down unit:

 

 

New Signs/Symptoms (S/S):

 Intermittently improved mental status

 Abdominal pain

 

 

Signs and Symptoms (S/S) over several days:

 Declining awareness, frequent disorientation and unconsciousness

 Pleural effusion

 Atrial arrhythmia

 Severe hypotension, refractory to intervention

 Anuria

 Massive generalized edema

 Oozing serous fluid from skin and puncture sites

 Fixed and dilated pupils

 

 

New Diagnosis (Dx):

 Possible metastasis to brain

 Later, possible “brain death”; permanent loss of higher brain function

 

 

Prognosis (Prx):

 Pt is actively and irreversibly dying and any intervention will only prolong life a short while

 

 

Goals of treatment

Note: Goals of medical care should not be confused with patient preferences for care; the goals of care 

are what medicine could reasonably hope to accomplish in terms of benefit and avoidance of iatrogenic 

(i.e. health care caused) harms.

1. Allow natural death; because the pt has lost higher brain function, the patient can no longer 

experience pain or its relief, so “relief and support” is not an attainable goal.

2. Education and counseling of patient re her condition and prognosis