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 prioritize Mr. Johnson and his family at the center of care to some extent. They gathered as an interprofessional team to discuss Mr. Johnson’s condition, potential treatment options, and the family’s wishes. They also arranged a meeting with the family to explain the options and the team’s recommendations, which shows an effort to involve the family in the decision-making process. However, it is essential to consider Mrs. Johnson’s strong desire to continue life support, which may not align with the team’s recommendation. Balancing the patient’s best interests with the family’s wishes can be challenging in such situations.
2. Mr. Johnson’s dignity, privacy, and confidentiality were respected to a certain extent. The healthcare team maintained confidentiality by discussing Mr. Johnson’s condition and treatment options within the appropriate medical setting, such as during the family meeting. However, respecting his dignity and privacy also involves ensuring that the family’s cultural and emotional needs are taken into account. Mrs. Johnson’s wishes and emotions, though in contrast to the medical recommendation, should also be considered respectfully and empathetically.
3. The nurse demonstrated high standards of ethical conduct by actively participating in the interprofessional team’s decision-making process and ensuring that the family was informed about Mr. Johnson’s condition and the available options. The nurse acted as an advocate for the patient’s best interests and communicated this to the family.
4. The team members respected and embraced the individual differences of Mr. Johnson’s family members to some extent. They presented the medical information and options clearly and listened to the family’s concerns and desires. However, there is room for further exploration of Mrs. Johnson’s emotional and cultural perspectives, which may differ from the medical perspective. The team needs to continue to engage with the family to better understand and address their specific needs and values.
5. The team members behaved with honesty and integrity according to high ethical standards by presenting the medical information truthfully and transparently. They made it clear that Mr. Johnson’s condition was unlikely to improve and that the recommended course of action was based on medical expertise and the patient’s best interests. However, they also respected Mrs. Johnson’s autonomy and her right to make decisions regarding her husband’s care, even if it differed from their recommendation.
6. When working through the case using an ethical decision-making process, it is important to consider the following steps:

   a. Gather all relevant information: The team gathered information about Mr. Johnson’s condition, the available treatment options, the family’s wishes, and the financial implications.

   b. Identify the ethical principles at stake: Key ethical principles include autonomy (respecting Mrs. Johnson’s decision-making authority), beneficence (acting in Mr. Johnson’s best interests), non-maleficence (avoiding harm to Mr. Johnson), and justice (fair allocation of resources).

   c. Generate alternative courses of action: The team should explore various options, such as continuing life support, seeking a second medical opinion, discussing the financial aspects with the family, and engaging in further dialogue with Mrs. Johnson to understand her perspective better.

   d. Evaluate the alternatives: Assess each option’s potential benefits and risks, considering Mr. Johnson’s quality of life, his family’s emotional well-being, and the financial burden.

   e. Make a decision: Based on a thorough assessment of the alternatives and ethical principles, the team may conclude that the recommended course of action aligns best with Mr. Johnson’s best interests. However, they must also respect Mrs. Johnson’s autonomy and involve her in the final decision.

   f. Implement the decision: If Mrs. Johnson agrees with the team’s recommendation, they can proceed with the withdrawal of life support while providing comfort care. If she continues to refuse, they must respect her decision, but maintain open communication and offer support for her and the family.

   g. Evaluate the decision and its consequences: After the decision is implemented, the team should regularly assess Mr. Johnson’s comfort and the family’s emotional well-being. Adjustments may be necessary based on their ongoing needs.

   h. Continue to support the family: Regardless of the decision made, the healthcare team should provide emotional support, information, and resources to help the family cope with the situation and navigate their options.