AMA Journal of Ethics^®

Case

Mrs. Jones is an 82-year-old nursing home resident with a longstanding history of heart failure, who is now hospitalized in the cardiac ICU for the third time this year. She is a retired teacher, with 4 children and 8 grandchildren. She did not list a religious preference when admitted to the hospital. The attending cardiologist, Dr. Rosenberg, is a heart failure specialist, and is an active member of an Orthodox Jewish congregation.

On day 3 of her hospitalization, Mrs. Jones developed a fever, which was subsequently determined to be caused by a MRSA line infection from a venous catheter. On day 4, her renal function began steadily deteriorating, until her serum potassium reached dangerous levels.

She has been unconscious for 2 days, and, according to hospital records and her children, she has no advance directives to guide end-of-life care. Dr. Rosenberg requests a family conference with Mrs. Jones's children (her husband is deceased) to discuss their mother's prognosis and the appropriate next steps in treatment.

"I'm afraid that your mother's health is steadily deteriorating," Dr. Rosenberg tells Mrs. Jones's family. "She has a serious infection that has failed to respond to traditional antibiotics."

"How did she get this infection, doctor?" Mrs. Jones's daughter Jennifer asks.

"That's a good question. It's likely the result of an IV line we placed during her admission," Dr. Rosenberg replies. "Your mother's infection is caused by a resistant strain of staphylococcus that is common in intensive care units and hospitals, but we have more aggressive antibiotics we can use. I should also tell you that her kidneys are failing, and we'll need to begin dialysis to ensure that her electrolytes and fluid status are kept at normal levels. Despite this, I think there's a strong possibility she'll pull through."

At this point, Mrs. Jones's eldest son Franklin interrupts. "Look, doctor," he says, "My cousin was on dialysis for years, and, until he died, he was really miserable. I don't want my mom to have to go through that at this age. I think enough is enough. She's been in the hospital 3 times this year alone."

"I understand your concern," Dr. Rosenberg says, "but you should realize that your mother may not require long-term dialysis. Her kidneys may recover, but at this stage, dialysis is the only solution left to correct her electrolyte imbalances. If we don't lower her potassium, she'll likely develop a fatal arrhythmia."

Franklin looks at the rest of the family, who are shaking their heads. "Honestly, I think you shouldn't treat her any further. Even if it's not permanent, starting dialysis just isn't a path we want her to start on. And the 'aggressive antibiotics'—I don't see any reason to pour more substances into her already tired body. It's obviously her time to go. Can't you just give her something to make her comfortable?"

Dr. Rosenberg pauses for a moment and then tells Franklin. "We fully intend to keep her comfortable and continue treating her pain. As you know, I'm committed to doing what's best for your mother. But in good conscience, I can't stop treating your mother as long as there are reasonable courses of action that I could take to preserve her life. According to the principles that guide my practice of medicine, I cannot withhold life-saving treatment from any patient—especially antibiotic therapy and temporary dialysis, both treatments with uncontroversial efficacy."

Commentary 2

This case is that of an 82-year-old woman who resides in a nursing home. She has a history of congestive heart failure and severe cardiac disease with 3 hospitalizations in 1 year for similar complaints.

During the last admission she developed line sepsis with methicillin-resistant staphylococcal aureus, is now starting to develop acute renal failure, and is unconscious.

The doctor wishes to continue with different antibiotics along with temporary dialysis.

There is one son who relates the past experiences of a relative on dialysis, and he seems to feel that antibiotics and dialysis are futile. It is clear that this conflicts with the treatment recommendations, but it is unclear whether he has the authority to make decisions that could terminate his mother's life prematurely.

Advance Directives?

All too often cases like this are complicated by the lack of an advance directive. "Advance directive" is a term that refers to an individual's spoken and written instructions about future medical care and treatment. Advance directives can be used if the patient is unable to make his or her own decisions. Stating health care choices in an advance directive helps family and physicians understand a person's wishes about his or her medical care. In some cases advance directives list individuals who will serve as health care agents.

With all of our training and expertise as doctors, we are first to do no harm. In this case a change of antibiotics and a temporary dialysis does no harm. It could potentially make a difference in Mrs. Jones's outcome. In a case with no advance directives, health care choices are usually made by the family member whom the physician is able to contact. In situations such as this, where several family members are involved, the best approach is to gather all the siblings together and ask them to decide on 1 person to serve as spokesperson for the family. From that point on, talk only with that individual.

The physician should explain to the family that their mother has congestive heart failure, complicated now by line sepsis and acute renal failure. He or she should say that the suggested plan of treatment is short-term and will cause no discomfort and should try to make the family understand that congestive heart failure, sepsis, and acute renal failure are not necessarily long-term and are treatable with antibiotics. Short-term hemodialysis is needed to cleanse the blood of toxins and to remove excess fluid that contributes to congestive heart failure.

A primary goal of hemodialysis in this case is the resolution of Mrs. Jones's altered mental status, in order to get her to directly participate in the decision making process. If Mrs. Jones does not respond after this treatment, then a neurological consult is in order. If her clinical condition continues to deteriorate, bringing about clinical brain death, then options for withdrawal of treatment would be appropriately discussed with the family.

Clinical medicine more and more is becoming an issue of the value of life. How do we define "value"? How can a physician put a value on a life? We cannot and should not decide who lives and who dies. There are many temptations: medical care can become costly; insurance companies want to keep costs down; many people cannot afford health insurance. There are also pressures from outside the house of medicine. Yet, life is sacred and important, and our mission as physicians is to give the best possible care to our patients without judgment of race, financial background, education, or gender.

In our years of training, we must develop a sense of compassion, a sense of concern and empathy. A good thing to do is remember the Golden Rule, Do unto others as you would have them do unto you (Luke 6:31).

If you put medical expertise, knowledge, and skill together with compassion, your outcomes will be acceptable. In the case at hand, if you have followed this patient and feel that she can improve with additional treatment, then that should be considered.