27 Oct Sclerosis

Mr. Care, a 55-year-old man, was diagnosed with multiple sclerosis (MS) 15 years ago. For the past 12 years, he has experienced progressive deterioration and has not responded to medications currently approved to delay MS progression.  Mr. Care was living at home, although for the last two years, he has required assistance in all activities of daily living and was confined to bed.

 

Once Mr. Care was becoming dependent but when he still had decisional capacity, he had repeatedly emphasized to his family and physicians that he did not wish to be placed on permanent mechanical ventilation.

 

Over the past month, Mr. Care has been admitted to the Intensive Care Unit (ICU) three times for aspiration pneumonia, requiring mechanical ventilation. In that time, he has become increasingly confused, disorientated and less communicative.

 

Mr. Care was readmitted to the hospital in a coma for treatment of pneumonia and respiratory failure.  Neurologic consultation concludes that his respiratory insufficiency is secondary to the advancing muscular and neurologic deterioration of MS and that the respiratory failure was accelerated by his acute pneumonia. Given the progression nature of MS and its advance state, it is all but certain that Mr. Care will not survive weaning from the mechanical ventilator; if his life is to be prolonged a short while, he will require permanent ventilator support. It is also unlikely that he will regain decisional capacity. In sum, Mr. Care will not be medically benefitted continued ventilation.

 

The physician recommends forgoing CPR, because the intervention is expected to expose the patient to burdens without counterbalancing clinical benefits. This recommendation is consistent with Mr. Care’s wishes, expressed when he had capacity. Mr. Care has also assigned his wife the authority to make decisions on his behalf.

 

True/False: Given the information about Mr. Care’s clinical condition, have the conditions he specified for refusal of mechanical ventilation in his oral directives been met? 

 

 

 

True

 

 

 

False

 

 

 

2) On what basis should the DNR order be written

 

 

 

A. Patient preferences

 

B. Medical indications

 

C. A DNR order should not be written.

 

D. Best interests

 

 

 

3) Under Tennessee law which of the following carries the greater weight in decision making?

 

(Clue: What are the legal obligations of a surrogate? Is a surrogate legally free to disregard a patient’s known wishes? Or are surrogates bound by prior preferences if these are known and directly applicable to the current situation?)

 

 

 

A. The patient selected his wife as his health care agent.

 

 

 

B. The patient directed his physician (and family) not to place him on permanent mechanical ventilation.

 

 

 

4) Tennessee law is unclear on the status of “unilateral DNR orders” (when a physician  imposes a DNR over the objections of a patient or surrogate acting on the pt’s behalf).

 

On the one hand, physicians are not expected to provide interventions that are outside the standard care (as some surrogate demands for CPR in situations of “futility” might be);

on the other hand, completion  of a POST form generally requires the consent of the patient or the surrogate, if reasonably available.

In this case, the POST form reflected the pt’s previously expressed wishes, so it is not clear whether this is a “unilateral DNR” even if the wife/surrogate objects.

 

Given that knowledge, if Mr. Care’s wife is not in agreement with the DNR order, what should be the next step for the ICU attending physician?

 

 

 

A. Request an ethics consult

 

 

 

B. Write  unilateral DNR

 

 

 

C. Abide by the wife’s wishes

 

 

 

5) Explain your answer. Why is your recommended next step best?

 

 

 

 

 

6) What do we know about Mr. Cure’s quality of life preferences? Mr. Cure would not want to live if he were . . .

 

 

 

A. permanently confused

 

 

 

B. at the end-stage of his terminal condition

 

 

 

C. permanently dependent on mechanical ventilation

 

 

 

D. totally  dependent in all activities of daily living

 

 

 

E. permanently unconscious

 

 

 

7) Under Tennessee law, Mr. Care’s advance directive would be legal if witnessed by . . .  

 

 

 

A. a blood relative and a next-door neighbor (not in Mr. Care’s will)

 

 

 

B. a blood relative and an in-law

 

 

 

C. a next-door neighbor (not in Mr. Care’s will) and Mr. Care’s health care agent

 

 

 

D. a notary public

 

 

 

8) True/False. Under HIPAA, if the facility now treating Mr. Care receives Medicare or Medicaid payments for patient services,then federal law requires the facility to ask if Mr. Care has completed an Advanced Directive.

 

 

True

 

False

 

 

 

9) What would have been the best time for completing a POST form for Mr. Cure requesting a DNI order (Do Not Intubate) if his future baseline respiratory status indicated he would remain vent-dependent for life?

 

 

 

 

 

A. When he developed chronic aspiration pneumonia secondary to end-stage MS

 

B. When he progressed to a dependent state 2 years ago

 

C. Mr. Cure does not yet need a POST

 

D. When he was diagnosed with MS 15 years ago

 

 

 

10) What would be the value  of a completed POST form in Mr, Care’s case?

(select all that apply)

 

 

 

A. Completing a POST provides an opportunity to clarify the patient’s preferences for all those involved in his care.

 

B. A POST converts Mr. Care’s statement of refusal of permanent ventilation into a physician’s order.

 

C. A POST is a physician order; physician orders direct the healthcare team.

 

D. A POST does not have value for Mr. Care because he is too near death.