AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2005, Volume 7, Number 1.

Module 5

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Case 5.3: Withdrawing or Withholding Treatment—Respecting Patients' End-of-Life Decisions

Case Presentation

Dr. Lee prescribed Mrs. Scott a low-dose opiod patch and anti-nausea medication. He also recommended that Mrs. Scott undergo a psychological evaluation for depression and maintain an ongoing relationship with the medical oncologist. A few weeks later, Dr. Lee received a call that Mrs. Scott was en route to the hospital. She had passed out while her sister was visiting and had knocked her head against a coffee table. Upon arriving at the hospital, Dr. Lee discovered that Mrs. Scott had lost even more weight and was dehydrated. Her heart rate was a little low and her blood pressure was weak but steady. The most significant concern at that point was the possibility of an internal cranial hemorrhage. Mrs. Scott was not conscious, and her sister agreed to have her undergo a head CT to determine if there was internal bleeding.

As they waited for the head CT, Mr. Scott arrived and informed Dr. Lee that his wife had not been eating regularly, though she had been keeping close contact with her family and friends. Everyone, it seems, had been encouraging her to seek hospice services, a course of action she resisted.

The neurosurgeon informed Mr. Scott and Dr. Lee that the CT showed several small acute subdural hematomas, but no edema. She recommended observation with daily re-evaluation. She suggested that, at least for a few days, Mrs. Scott might not be consistently lucid. Over the next several days, as expected, Mrs. Scott cycled through periods of lucidity and confusion. Although she was not worsening, she also was not eating—her albumin was very low and she was losing even more weight. The medical oncologist, Dr. Walker, recommended the placement of a PEG tube—if Mrs. Scott was to reverse her cachectic state and improve her quality of life, she would need better nutrition. Because of Mrs. Scott's compromised condition, Mr. Scott was asked to consent, which he did.

Over the next several days, Mrs. Scott's periods of confusion were diminishing and the subdural hemotoma was resolving with no lasting effects or edema. Her albumin levels had increased and she even gained a little weight. As she became more and more consistently lucid, she requested that the PEG tube be removed. Finally, she asked Dr. Lee to remove the PEG tube. After a short conversation, he recommended that they meet the next day with her family and the medical oncologist.

To begin the meeting, Dr. Lee and Dr. Walker describe Mrs. Scott's diagnosis and prognosis and identify her possible courses of treatment, including aggressive therapy, palliative care, and no treatment. They describe in some detail the risks and benefits of each course and recommend palliative care including the PEG. Mrs. Scott seems to accept their recommendation. She explains that she has suffered long enough and asks Dr. Lee to recommend a hospice facility. Before he has chance to respond, she adds, "But first, as I asked you yesterday, I'd like you to remove the PEG tube."

What should Dr. Lee do? (select an option)

A.   Order the removal of the PEG tube.
B.   Ask Mr. Scott to persuade Mrs. Scott to keep the PEG tube in.
C.   Call for a psychological evaluation of Mrs. Scott.
D.   Inform Mrs. Scott that he will not remove the feeding tube.
The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.