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NURS412 NURSING CARE AT END-OF-LIFE

Week 5 Discussion

Case Studies Involving Ethical and Legal Issues (Group I)

Review

Joleen Wright, an 87-year-old woman, living in a nursing home, had been pleasantly convivial and moderately demented for some time. No family or friends were known. It was tough to discern her preferences, as she “lived in the present” and did not trouble herself about future possibilities. She had chronic hypertension and hearing and motion deficits.

Over a few weeks, she gradually started doing “poorly,” walking less, eating less, and seeming more distant. Over the next two weeks, a comprehensive evaluation in her nursing home setting turned up very little. Blood tests, physical exams, and chest x-rays were all normal, but she then became short of breath and was hospitalized. By the time she arrived at the emergency room, her blood pressure had declined to dangerous levels. She had mild problems with oxygenation, probably due to pulmonary edema, and was started monitoring and careful fluid balance. Within 24 hours, she had multiple interventions (e.g., IV, cardiac monitor, urine catheter) for monitoring and treatment and was restrained in bed to keep the connections in place. Her skin was breaking down on her shoulder blades. She indicated “yes” or “no” to questions about her comfort but showed little insight or attention. No definite reversible diagnoses surfaced despite appropriate work-up. Her condition worsened, and she faced the need for mechanical ventilation. The care team anguished over whether to continue intrusive care in the intensive care unit to establish a precise diagnosis or shift toward a primarily palliative approach. Her condition continued to deteriorate, and she became minimally responsive.

After a team meeting, the care team decided to institute hospice-type care and not seek a court’s involvement in getting a guardian. Joleen Wright died comfortably 36 hours later. Because no consent to autopsy could be obtained, the diagnosis remained a mystery.

Initial Post Requirements

hould age be a deciding factor in the provision of care? Why or why not?

Should we allow people to die from aging without knowledge of a primary terminal disease process?

What care would you want if this were you? How do your personal values influence your preferences?

What role could a nurse play in addressing the ethical issues in this case?

Case Studies Involving Ethical and Legal Issues (Group 2)

Review

Ms. J.F. is a 48-year-old woman in apparent good health until 2 months before consulting her physician when she reported progressive abdominal swelling and weight gain. Associated symptoms included fatigue, loss of appetite, gastric fullness, nausea, diarrhea, and intermittent leg swelling. She had become unable to perform her usual activities as a legal secretary and mother of a 19-year-old autistic son. She is divorced and has had a stable relationship with Robert, a school director, for 5 years.

On physical examination, she is afebrile, alert but pale, and in obvious discomfort. There is dullness and decreased breath sounds at the left lung base. She has marked abdominal distention with a fluid wave. There is moderate non-localized abdominal tenderness to palpation. Rectal and pelvic examination demonstrates a non-tender mass in the cul-de-sac. She is admitted to the hospital for further evaluation and management.

Laboratory and diagnostic results include the following: CBC, electrolytes, serum calcium, and liver function tests are normal. Serum albumin is decreased. The chest X-ray demonstrates a small left pleural effusion. Pelvic ultrasound shows ascites and a regular-sized uterus; the ovaries are not visualized. Abdominal CT scan reveals no organomegaly, but retro-crural adenopathy is present. Bone scan and esophagogastroscopy with biopsy are normal. Colonoscopy confirms an extrinsic, compressing mass at 5 cm. There is diverticulosis but no intrinsic mass.

Paracentesis cytology is positive for undifferentiated adenocarcinoma. The tumor marker results are as follows: CA 15:3: normal; CA 125: slightly increased; CA 19:9: moderately increased; CEA: normal.

During the first week of admission, Ms. J.F. becomes weaker with increasing diffuse abdominal pain and a sensation of pressure on the perineum. She also develops moderate dyspnea and persistent nausea and vomiting. It is thought that she does not have a bowel obstruction; instead, her symptoms are explained by ascites and involvement of the parietal peritoneum. The ascites reaccumulate, requiring repeated paracentesis. It is decided to give her an albumin transfusion replacement, morphine, intravenous metaclopromide, and dimenhydrinate.

An interdisciplinary group meets to discuss her care and determine what limits should be placed regarding further investigations relative to her condition and likely prognosis, i.e., the benefit of identifying the adenocarcinoma’s primary site vs. the projected poor outcome and excess burden to the patient.

Initial Post Requirements

As a team member, how would you proceed, and what would you consider in the decision-making process?

What factors will assist you in determining the limits in this case?

How does the issue of futility influence your opinion?

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Case Studies Involving Ethical and Legal Issues (Group 3)

Review

As recommended by the interdisciplinary team, the attending physician proposes to Ms. J.F. the option of an empiric chemotherapy trial. The physician explains that the malignancy is widely disseminated, that chemotherapy might slow down the ongoing process, and that she might experience some side-effects from the therapy. He is vague regarding the prognosis and potential value of the treatment. The physician does not want to needlessly alarm the patient or her companion, who is anxious and confused by the rapid progression of her condition. The physician wants to maintain their morale, saying “they have enough to deal with at this moment.” Consent is obtained from the patient for chemotherapy.

Initial Post Requirements

Why is consent a necessary component of therapy?

What variables can influence consent?

What are the requirements for consent?

How do you evaluate the competency of the patient?

Do you think that the consent was valid and without influence? Further explain your answer.

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Case Studies Involving Ethical and Legal Issues (Group 4)

Review

Ms. J.F. does not respond to chemotherapy. Her pain increases to the point that she can assume no comfortable position and is in constant pain despite all analgesic therapy, including increasing doses of morphine. She becomes more nauseated despite receiving different anti-emetics. Her ascites continues to accumulate rapidly and requires repeat paracenteses to help alleviate increasing pain and dyspnea. Her serum albumin continues to drop despite replacement. She develops thrombophlebitis, for which she receives heparin therapy. At this point, the patient is fatigued, dyspneic, and restless and must sleep in a sitting position. However, she remains conscious, alert, and oriented. Her competency is never in question, although she is partly sedated with lorazapam.

One morning she speaks to the attending physician. After inquiring about her disease’s extent and outcome and being reassured that everything possible is being done, she asks that all treatments be stopped. She states she is at the ‘end of the road’ and does not wish to go further. “I can’t bear it anymore. Please help me be comfortable. Make me sleep.”

Throughout her illness, she is supported by her companion, who loves her dearly. He has wanted everything done to restore her health. However, when confronted by her demand, he agrees that the situation is complicated and very painfully shares her decision. The patient asks to see her son, who is taken to the hospital for a brief visit.

Initial Post Requirements

ow would you clarify this request? Is this withholding of treatment?

Is sedation an acceptable treatment for relieving Ms. J.F.’s symptoms?

What is the ethical rationale for your decision?

How are sedation and withdrawal of treatment different from assisted suicide or euthanasia?

Ms. J.F. is reassured that everything will be done to make her comfortable. The intravenous line and heparin are discontinued. She is put on higher doses of continuous subcutaneous infusion of morphine; midazolam and haloperidol are given subcutaneously twice daily. She remains comfortable and dies peacefully 2 days later. She is conscious but sleepy until her death. During this difficult time, she is accompanied by her loved ones. Everyone is at peace because they have the impression they could express their feelings and discuss issues freely. The door is left open for communication and support. Bereavement counseling is made available to both Robert, her companion, and Ms. J.F.’s son.

Adapted from: Lesage, A.D. & Latimer, E. (1999). An approach to ethical issues. In N. MacDonald (Ed.), Palliative medicine: A case-based approach (p. 253-277). New York, NY: Oxford University Press. Reprinted with permission.

Each member of the group will discuss this case, respond to the questions, and participate in the initial post.

Case Studies Involving Ethical and Legal Issues (Group 5)

Review

Mr. B. is a 21-year-old African-American male who has been treated over the last year at your hospital for widely metastatic Burkitt’s Lymphoma. Mr. B. had lived at home with his mother, but a few months ago, against his mother’s wishes, he married his long time 17-year-old girlfriend, the mother of his 2-year-old son. His mother does not get along with the patient’s wife. The couple has a small apartment, and his wife has been trying to keep working nights as a nurses’ aide to support them. He’s applied for disability, but they currently have no consistent financial support source except her part-time job.

Unfortunately, after his first course of chemotherapy, he became septic and nearly died in the ICU. His disease has continued to progress through second and third-line treatment. He has been hospitalized almost continuously for dehydration and fevers for the last two months, among other problems.

He has been evaluated for a bone marrow transplant but has steadfastly refused it because “I don’t want my family to lose everything because it’s probably not going to work at this point.” He has told you that he was pressured by his mother to have the evaluation – “It’s really hard to say ‘No’ to her. Mom told me she’d take the hospital to court if they don’t do a full-court press. She’s already contacted a lawyer. My wife can’t stand up to her, so I guess I’ll end up doing it even though I don’t want to.”

Initial Post Requirements

What ethical principle/principles are at issue in this case?

Does this situation warrant ethics consult from the hospital ethics committee? If so, who should initiate it?

What, if any, legal issues should be examined?

What should patient/family issues be addressed?

What advocacy role do you have as the oncology nurse taking care of this patient?

Adapted from: ELNEC Core Curriculum, Module 4: Ethical Issues in Palliative Care Case Studies (January 2013).

ach member of the group will discuss this case, respond to the questions, and participate in the initial post.

 

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