End-of-Life Care Part 1

Case Study: End-of-Life Care Part 1

Steven Johnson is a 76-year-old retiree receiving Social Security and Medicare who suffered a severe cardiovascular accident (CVA) (commonly known as a stroke) while playing golf. His fellow golfers called 911, and Mr. Johnson was transported to the city medical center, where he was admitted. He is now on a ventilator, unable to communicate or breathe on his own. He does not have a living will, and his 71-year-old wife, Nancy, states that she wants everything possible done. Mrs. Johnson calls their pastor and asks him to pray for Mr. Johnson’s recovery. The Johnsons are planning to celebrate their 50th wedding anniversary in 3 months and Mrs. Johnson insists that her husband will get well in time for that. The Johnsons have two adult children who live within an hour’s drive of the Johnsons.

Mr. Johnson’s healthcare team consists of a respiratory therapist, hospitalist physician, neurologist, nurse, and pharmacist. They decide to include a social worker/case manager on the team. It becomes clear that Mr. Johnson will not recover enough to have any quality of life. He has severe, irreversible brain damage, with no possibility of meaningful recovery. He will never be able to communicate, nor will he be able to breathe on his own. The team agrees that it would be in Mr. Johnson’s and his family’s best interest to remove him from life support and let him die peacefully. The team decides that the social worker should arrange for a meeting with the interprofessional team, including the family, to explain the options and the team’s recommendations.

The meeting takes place in the hospital family meeting room. Mrs. Johnson and both of her children are present. The neurologist explains Mr. Johnson’s condition and the likelihood that he will never improve, and that the team recommends removal from the ventilator, which will most likely result in death within hours, although it may take longer. He reassures the family that Mr. Johnson will be kept comfortable and free from pain. Mrs. Johnson becomes angry and vehemently refuses to consent to have him removed from the ventilator, insisting he will get better and attend their 50th anniversary party. Mr. Johnson’s children inquire about the cost to keep him on the ventilator and are told that most Medicare plans will pay 80% of the cost, with the family being responsible for 20%, if the ventilator is deemed medically necessary, but that he will find out the details regarding what Mr. Johnson’s plan will and will not cover. The social worker tells the family that there are no facilities in the area for ventilator-dependent patients, including hospice care. Mr. Johnson could go home on the ventilator but would need 24-hour care, and the family would need to rent a ventilator, which would require a physician prescription stating it was medically necessary, and only certain conditions are covered for ventilator use. Overall, the cost of Mr. Johnson’s continued care would deplete the Johnsons’ resources with little to no chance of Mr. Johnson improving. Mrs. Johnson’s children try to convince her that the best thing for everyone is to remove him from the ventilator, but she refuses, and the meeting ends with the team stating their availability to discuss matters further at a later date if the family desires.

After the meeting, the Johnson children contact the social worker/case manager and ask him how they can force their mother to “do the right” thing. The social worker states that it is their mother’s decision as she is next of kin and in her “right mind.” There is nothing the team can do other than present her with the options and their recommendation. He suggests that Mrs. Johnson and her children take some time to let the information sink in and to discuss it further with Mrs. Johnson’s pastor.

Discussion Questions

1. Did the nurse and the healthcare team place Mr. Johnson and his family at the center of care? Explain your answer.
2. Were Mr. Johnson’s dignity, privacy, and confidentiality respected in this scenario? Explain your answer.
3. How did the nurse demonstrate high standards of ethical conduct in this situation?
4. How did the team respect and embrace the individual differences of Mr. Johnson’s family members?
5. How did the team members behave with honesty and integrity according to high ethical standards in this situation?
6. Work through the case using an ethical decision-making process. Consider role-playing with others taking the roles of the healthcare professionals and family members.

Title: Case Study: End-of-Life Care Part 1

Introduction: The case of Steven Johnson, a 76-year-old retiree who suffered a severe cardiovascular accident (CVA), presents a complex ethical and emotional dilemma in the context of end-of-life care. This essay will analyze the scenario and discuss the ethical considerations surrounding the decision-making process of Mr. Johnson’s healthcare team, his family, and the role of the nurse and social worker in providing care and guidance.

1. Placing Mr. Johnson and His Family at the Center of Care: The healthcare team, comprising a respiratory therapist, hospitalist physician, neurologist, nurse, pharmacist, and a social worker, initially placed Mr. Johnson and his family at the center of care by involving them in the decision-making process. They convened a family meeting to explain Mr. Johnson’s condition, the prognosis, and the team’s recommendation to remove him from life support. This approach ensured that the family was informed and included in the decision-making process. However, Mrs. Johnson’s strong refusal to consent posed a challenge to this patient-centered care approach.
2. Respecting Dignity, Privacy, and Confidentiality: Respecting Mr. Johnson’s dignity, privacy, and confidentiality is a critical ethical consideration in end-of-life care. The healthcare team upheld these principles by conducting the family meeting in a designated family meeting room, away from public areas. They also maintained confidentiality by discussing sensitive medical information only with authorized family members present at the meeting. However, it is essential to consider whether Mr. Johnson’s wishes and dignity were respected, given his inability to express his preferences and his wife’s strong stance against removing life support.
3. High Standards of Ethical Conduct by the Nurse: The nurse in this scenario demonstrated high standards of ethical conduct by actively participating in the family meeting and providing essential information to Mr. Johnson’s family. The nurse acted as an advocate for Mr. Johnson by ensuring that his family understood the gravity of his condition and the implications of keeping him on a ventilator. Additionally, the nurse conveyed empathy and compassion while explaining the situation, maintaining the highest ethical standards in end-of-life care.
4. Embracing Individual Differences of Family Members: The healthcare team recognized and respected the individual differences among Mr. Johnson’s family members. They engaged in a balanced and empathetic approach when addressing Mrs. Johnson’s insistence on continuing life support. Furthermore, they addressed the concerns of Mr. Johnson’s children regarding the financial implications of long-term care. By acknowledging these differences and presenting options without judgment, the team demonstrated sensitivity to the diverse needs and perspectives within the family.
5. Behaving with Honesty and Integrity: The healthcare team exhibited honesty and integrity by providing accurate information about Mr. Johnson’s condition, prognosis, and the financial aspects of care. They did not withhold any critical details from the family, allowing them to make an informed decision. The team’s commitment to transparency and truthfulness aligns with ethical principles in healthcare decision-making.
6. Ethical Decision-Making Process: To navigate this complex ethical dilemma, an ethical decision-making process should be followed:

a. Identify the ethical issue: The central issue is whether to continue life support for Mr. Johnson against medical recommendations due to the family’s wishes.

b. Gather information: The healthcare team provided information about Mr. Johnson’s condition, prognosis, and the financial implications, ensuring the family had a comprehensive understanding.

c. Identify stakeholders: Key stakeholders include Mr. Johnson, his wife, children, and the healthcare team.

d. Evaluate options: Options include respecting Mrs. Johnson’s wishes to continue life support, considering alternatives for care, and engaging in further discussions with the family.

e. Make a decision: The decision should be guided by the best interests of Mr. Johnson, considering his autonomy, the medical prognosis, and the family’s wishes.

f. Implement the decision: Once a decision is reached, it should be implemented with empathy and sensitivity.

Conclusion: The case of Mr. Johnson highlights the intricate ethical considerations surrounding end-of-life care. The healthcare team’s commitment to patient-centered care, ethical conduct, and respect for individual differences is evident in their approach. However, the case also underscores the challenges posed when a patient’s family strongly opposes medical recommendations. Ethical decision-making in such scenarios demands careful consideration of the patient’s best interests, family dynamics, and the principles of autonomy and beneficence. Part 2 of this case study will further explore how these ethical dilemmas are resolved.