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.

1. The nurse and the healthcare team did place Mr. Johnson and his family at the center of care by involving them in the decision-making process and considering their wishes and concerns. They arranged a meeting to discuss the options and recommendations with the family, ensuring transparency and communication. However, Mrs. Johnson’s strong insistence on continuing life support despite the medical team’s recommendations created a challenge in fully aligning with patient-centered care.
2. Mr. Johnson’s dignity, privacy, and confidentiality were respected to some extent in this scenario. The healthcare team held a private meeting with the family to discuss his condition, which maintained his privacy. However, the family was informed about his medical condition and the recommendation to withdraw life support. The challenge here is balancing the need for transparency with respecting Mr. Johnson’s privacy, especially when Mrs. Johnson strongly disagrees with the recommendation.
3. The nurse demonstrated high standards of ethical conduct by providing clear and honest information to the family regarding Mr. Johnson’s condition and the medical team’s recommendations. The nurse also reassured the family that Mr. Johnson would be kept comfortable and free from pain, which reflects a commitment to compassionate care. Additionally, the nurse respected Mrs. Johnson’s wishes, even though they differed from the team’s recommendation, reinforcing the importance of patient autonomy.
4. The team members respected and embraced the individual differences of Mr. Johnson’s family members by inviting them to the meeting and listening to their concerns and perspectives. They acknowledged Mrs. Johnson’s role as the next of kin and her right to make decisions for her husband, even though her decision differed from their recommendation. The team recognized that each family member had their own views and emotions related to Mr. Johnson’s care.
5. The team members behaved with honesty and integrity according to high ethical standards by providing accurate information about Mr. Johnson’s condition and the options available. They did not attempt to manipulate or coerce the family into making a specific decision. Instead, they presented the facts and allowed the family to make an informed choice based on their values and beliefs.
6. An ethical decision-making process involves several steps, such as:

• Identify the problem or dilemma: The problem is whether to continue or withdraw life support for Mr. Johnson.
• Gather information: The healthcare team provided medical information, cost implications, and available options to the family.
• Identify potential solutions: The options include continuing life support or withdrawing it.
• Consider ethical principles: Respect for autonomy (Mrs. Johnson’s right to make decisions), beneficence (doing what is best for Mr. Johnson), non-maleficence (avoiding harm to Mr. Johnson), and justice (considering the allocation of resources) are relevant ethical principles.
• Make a decision: The family, particularly Mrs. Johnson, has the authority to make the final decision. The team can provide recommendations based on ethical principles, but the decision ultimately rests with the family.
• Implement the decision: The team should respect and carry out the family’s decision, whether it is to continue or withdraw life support.
• Evaluate the decision: The team should continue to provide support and communication to the family, addressing any concerns or changes in the decision.

Ultimately, the ethical decision-making process in this case respects the autonomy and values of the family while providing them with the necessary information and recommendations to make an informed choice regarding Mr. Johnson’s end-of-life care.