A Case Study by Robert L. Potter
Discussion Questions by Rosemary Flanigan
A forty-five-year-old man with a three-year history of cardiovascular disease has entered the hospital with a stroke that has paralyzed his right side and caused him to aspirate food of any consistency. His mental status is clouded and there is disagreement as to whether or not he has decisional capacity. His language capacity is only “yes” and “no,” and his responses are inconsistent. The attending physician is convinced that the patient has lost decisional capacity while two family members are equally convinced that he has decisional capacity. The patient’s wife and two other children are ambivalent about his competency to make decisions. The prognosis for recovery of safe swallowing and speech approaches zero because of the dense damage to the cerebral cortex visible on brain imaging. Two neurological consultants have verified that recovery is likely to be minimal and that permanent, severe disability will be the outcome.
The patient does not have an advance directive. The patient’s wife says that they never did discuss his preferences about life-sustaining treatment. She is convinced that he would not want to live in this disabled condition, but is uncertain whether to request the placement of a feeding tube. Two of her four adult children are strongly opposed to the tube placement, while the other two insist that not to do so would be to “kill our father.” The patient’s wife is torn between these two positions, but finally requests that the tube be placed.
The attending physician and the rest of the treatment team are opposed to placing the feeding tube. Their argument is that the patient has “minimal consciousness” and will not improve. They define this as a futile situation with no reasonable expectation of recovery. Furthermore, two nurses claim that during previous hospitalizations for episodes of cardiovascular events the patient told them that he would not want to be sustained by artificial means — not by ventilators, renal dialysis, or tube feeding. It is their position that the patient has expressed his preference to not be kept alive in a futile situation.
The family requests an ethics consultation.
QUESTIONS FOR DISCUSSION
1. The judgment of futility should be a conclusion of a communications process, not a beginning. How would you propose beginning the communication?
• Who should be present?
• What information should be shared?
• What alternatives are on the table?
• What is your goal in participating in the discussion?
2. The family is divided over whether or not their husband/father should be placed on a feeding tube. Consider and discuss the following statements:
• The effectiveness of the feeding tube is a clinical matter.
• The benefits of the feeding tube for the patient depend on the patient’s wishes and quality of life, which the patient or the patient’s surrogate and family must determine.
• The burdens the treatment (feeding tube) imposes are a consideration for both parties.
3. Role play the discussion. Express your assumptions and loyalties and listen attentively to the other speakers.
4. Evaluate the role playing experience. Did it affect your view of the case?
If yes, how will you advise the family and the healthcare providers? If not, what is to be done now?
5. How would this case have been different if the attending physician had been the one asking for a consultation?