Past Resident Medical Ethics Conference

Feel free to use our case conferences for educational purposes. We only ask that you credit this source when using our materials.

Ethical and Emotional Aspects of DNAR Orders

July, 2006

Case: Mr. B. is an 83-year-old man whose wife died of ovarian cancer last year. His health has generally been good, with the exception of surgery for colon cancer 6 years ago complicated by a pulmonary embolism. He has coronary atherosclerosis and moderate congestive heart failure managed with digoxin and diuretics. Because of progressive osteoarthritis of both knees, pain, and limitation of motion he came from his home in Florida to Salt Lake City for bilateral total knee replacement. He came so that he could convalesce from the surgery at the home of his son and daughter-in-law who live here. He had knee surgery in April. Postoperatively he developed a saphenous vein thrombosis that required anticoagulation and extended his hospitalization. After discharge he made steady progress with his walking. In late May he developed acute abdominal pain and was brought to the Emergency Room. At laparotomy, small bowel ischemia was noted and 16 cm of small intestine was removed. He had 3 successive explorations to identify any additional ischemic segments. He developed an I.V. catheter associated bacteremia with staphylococcus aureus and an abdominal wound infection with gram negative rods. During his 4 weeks in the hospital he has become progressively depressed. He recently developed several episodes of chest pain with EKG changes of ischemia and was transferred to the medical service. Drugs have been only marginally effective in controlling the pain. A cardiologist has recommended angiography with PTCA if possible, or coronary bypass surgery. The housestaff have just rotated. The resident says to his new intern that a DNAR order might be appropriate for Mr. B. The intern agrees and plans to talk with Mr. B.. You are the intern. You have about 10 minutes after work rounds before attending rounds start and you decide to talk to Mr. B. You reviewed his chart last night and met Mr. B. on rounds, but you haven't really gotten acquainted. You haven't had much experience talking with patients about DNAR order. As a student you recall that most of the time they were discussed with family members because patients were confused or unable to communicate. You're not looking forward to this but it seems like one of your duties so you take a deep breath and walk toward Mr. B's room.

To understand the range of issues that may arise in the course of these discussions.
To understand the respective roles of doctors and patients in a DNAR discussion.
To learn how to conduct a DNAR discussion that minimizes fear and anxiety in both parties, transmits relevant information effectively, and leads to a thoughtful and informed decision.

Advance Directives: When Do They Work and How?

August, 2006

Mrs. L is a 76-year-old widowed white female brought to the emergency room by the paramedics because of dyspnea and confusion. She has a past medical history of severe osteoarthritis, congestive heart failure, and progressive dementia. She had been living with her daughter and son-in-law for the past two years. When she moved in with her daughter, after losing her husband to a series of debilitating strokes, Mrs. L told her daughter that she preferred to continue living alone, but realized that she was unable to do so. She also said that she never wanted to live in a nursing home. Shortly after moving to her daughter's home, Mrs. L completed a living will. She used the form provided by the Utah Medical Association. She also told her daughter on several occasions that she was ready to die and was looking forward to being reunited with her husband. During the last six months her dementia had progressed considerably. Although she was not always sure with whom she was speaking, she remained affable, easy to take care of, and able to communicate most of her basic needs. On her regimen of diuretics and cardiac medicines her symptoms were moderately well controlled, but she had persistent shortness of breath with exercise and dependent edema. On the night of her admission she became extremely short of breath and her daughter called for assistance.

Shortly after the ambulance arrived with Mrs. L, her daughter and son-in-law arrived. They learned that in the emergency room the patient's blood pressure had fallen; she developed ventricular tachycardia and respiratory distress. The physicians were in the process of cardiopulmonary resuscitation and tracheal intubation. Mrs. L's daughter asked them to stop, asserting that her mother had a "living will." The physicians were unwilling to desist and stated that because they did not know the cause of the patient's problems they had to proceed with life-saving intervention and diagnostic studies. Their efforts at resuscitation were successful and the patient was admitted to the intensive care unit. Mrs. L's daughter appeared in the intensive care unit shortly thereafter and asked to speak to the physician taking care of her mother. Mrs. L's resident met with the patient's daughter in the family conference room. The daughter asked the resident to discontinue the life-supporting measures that were in place and she presented him with the signed, original copy of her mother's living will.

Objectives:

Residents will understand the rationale for advance directives from the doctor's and patients' perspectives.
Residents will discuss evidence about the effects of advance directives on patients and medical practice.
Residents will identify ways they can reduce conflicts and misunderstandings about life-sustaining treatments.

Withdrawing Medical Treatments: The Decision and the Process

September, 2006

Mrs. B is an 84-year-old woman who was transported to the emergency room from a local nursing home. The reason for the transfer was a two-day history of fever, cough, and worsening of her moderately severe dementia. Her past medical history included ASCVD with atrial fibrillation and congestive heart failure. She also had a right CVA with consequent left hemiplegia. She is confined to a bed or a wheelchair. She sometimes watches television, does not read and does not give reliable answers to questions. She doesn't always recognize her granddaughter who is the only relative who visits her.

The medical staff diagnosed pneumonia, intubated the patient, and began antibiotics. Although her condition stabilized after several days, she still remained ventilator dependent. The resident began to wonder whether withdrawal of ventilator support would be appropriate in this case and how that decision should be made.

Objectives

Residents will learn what skills and processes facilitate making a decision to withhold or withdraw medical treatment.
Residents will hear what state law and professional societies have to say about what can be withheld and who makes the decision.
Residents will hear how life support is typically withdrawn in the United States.
Residents will learn the process steps in medical management that maximizes comfort for patients, providers, and family.

The Resident Patient Relationship

October, 2006

Objectives:

To identify the essential elements and expectations in a doctor- patient relationship.
To examine how these may differ in a resident-patient relationship.
To consider how to achieve the best possible resident-patient relationship.

Telling the Truth When the News is Bad

November, 2006

Case: Mrs. H, a 37-year-old married white female, was admitted for progressive fatigue and fever of two days duration. A white blood count showed leukopenia. She was treated with empiric antibiotics. Cultures were negative.

On Friday morning the resident received the report of a bone marrow exam, which was characteristic of acute myelogenous leukemia. An oncologist was scheduled to see the patient in the afternoon. That morning, Mrs. H. asked her resident if she knew the results of the biopsy. The resident paused before answering.

Objectives:

To recognize why telling bad news is so difficult for physicians.
To understand how patients receive and process disturbing information.
To have a plan for how to communicate bad news effectively and compassionately.

Impaired Health Professionals: What to Do When Colleagues Need Help?

December, 2006

John D. was a graduate of a prestigious eastern medical school and had done exceptionally well during the first three months of his internship. Recently, however, his colleagues had noted that he looked quite fatigued even on non-post call days, and he sometimes complained to them of abdominal pain or indigestion. Nurses began to report to his resident that his relationships with them had deteriorated and he was frequently angry for seemingly inappropriate reasons. An attending commented to his resident that John was often late to rounds and that he didn’t always seem completely up-to-date on developments and data related to his patients.

John’s past medical history was essentially unremarkable. His social history revealed that he was the oldest of three children. His mother was a public relations specialist and his father was an attorney. His parents were divorced when he was 15. His mother is alive and his father died recently from cirrhosis.

Objectives:

To think about how to distinguish between impairment and low level, but acceptable, performance. To construct a differential diagnosis for impaired performance.
To learn how to present concerns about impairment to an affected colleague.
To know what professional support and assistance is available.
To recognize the tension between loyalty, personal comfort, self interest, and patient care that makes this such a difficult problem.

Medical Mistakes: How Do We Deal with Them?

January, 2007

Dr. R. was a 78-year old, retired family physician with a history of ASCVD, two prior MI’s, a coronary artery stent and congestive heart failure. He presented with a 1-month exacerbation of his cough and shortness of breath and loss of appetite and weight. He had been self-medicating his CHF without improvement. His chest x-ray showed RUL consolidation and a diffuse infiltrate consistent with pulmonary edema. He was treated for community-acquired pneumonia and CHF. On Day 6, he developed respiratory failure and was transferred to the ICU. There, consultation with Infectious Disease and pulmonary specialists established that he had disseminated tuberculosis. Despite institution of appropriate anti-TB therapy, he expired on Day 8.

OBJECTIVES:

To define what counts as a medical error and identify factors that may have contributed to it.
To consider who should learn about this mistake and why.
To learn how residents and residency programs deal with mistakes.

Malpractice: How Does the Law Deal with Medical Mistakes

February, 2007

CASE: Mr. Y, a 58-year old white male with a long history of asthma, was admitted to the hospital with RUQ pain. Evaluation disclosed a metastic liver tumor and colon cancer. The primary colon lesion was in the rectum 6 cm above the anus. Mr. Y, when apprised of his diagnosis and poor prognosis, asked his resident if the colon cancer could have been discovered earlier and treated more effectively. The resident, who had reviewed the records of the patient’s frequent clinic visits for asthma, found no record of a rectal exam or colonoscopy. She was unsure of what to say and worried about the risk of one of her colleagues being sued for malpractice.

Objectives:

Learn what elements must be present for an action to be regarded as malpractice.
Learn how the “standard of care” concept applies in the hospital and in the courtroom, specifically with regard to this case.
Become familiar with the epidemiology of malpractice claims, settlements and verdicts.
To understand what situations may place physicians at greater risk for potential malpractice claims and understand what steps may be utilized to reduce the risk of such claims.

Medical Futilty

March, 2007

CASE: An elderly man who lives in a nursing home is admitted to the medical ward with pneumonia and confusion. The admitting resident proposes a plan that includes antibiotics, but excludes CPR and transfer to the ICU because she thinks those interventions would be futile. She plans to share her plan with the patient’s family.

OBJECTIVES:

To try to reach a consensus definition of medical futility.
To be aware of the AMA's current opinions on medical futility in end-of-life care and futile care.
To appreciate the difference between futility and rationing.

Disparities and Discrimination in Medical Treatment

April, 2007

Case:
Coretta Brown, a 63-year-old African-American woman was seen in the Outpatient Clinic by an Internal Medicine resident (male, Caucasian, age 28). She was in the clinic for follow up on her diabetes hypertension and renal insufficiency. All were under fair control. The resident, as he routinely did, asked if she had an Advance Directive. She did not. He explained what it was and asked if she wanted to complete one. She declined.

Over the ensuing two years she had a series of small strokes and became mentally incapacitated. Her renal failure worsened. Her daughter agreed when dialysis was proposed and she asked about the possibility of renal transplant. The nephrologists (female, Caucasian, 40) listed Mrs. Brown as a potential recipient, but no compatibility kidney became available. Her mental status continued to deteriorate. Her daughter continued to care for her mother and bring her regularly to her dialysis session.

Discussion Questions:

In what ways does age (of patient, daughter, and doctors) influence this case history?
In what ways does gender (of all parties) affect this narrative?
In what ways does race affect the decisions, recommendations, and events in cases like this one?
What assumptions have you made about class in this case? How would class or difference in class between parties matter in cases like this?
What, if anything, should physicians know specifically or do differently when they treat families of a different race, age, gender, or class?

Objectives:

Participants will hear and read the evidence that led the Institute is Medicine to its conclusions about unequal treatment.
Participants will explore the relationship between their medical practice and the report’s conclusions about unequal treatment.
Participants will consider steps to take that would lead to “equal treatment.”

The Difficult Patient

May, 2007

Case:
A 45-year-old alcoholic man named George had numerous ER visits and admissions to the hospital over the past six years for acute gastrointestinal bleeds and, most recently, a nearly fatal subdural hematoma. He was discharged on a Monday. He returned to the ER on the following Tuesday with lacerations that required stitches. He was seen again on Thursday and was casted for a fractured arm. He reappeared on Friday with profusely bleeding esophageal varices. Despite multiple transfusions he died later that night. The first year resident muttered "Thank God" and the senior resident said "amen," quite audibly.

Adapted from Taking Care of the Hateful Patient by James E. Groves, M.D.

OBJECTIVES:

To identify what characteristics in patients and ourselves that lead us to characterize some patients as difficult or hateful.
To be able to interpret our feelings of anger, resentment and discomfort when they are directed toward patients.
To develop strategies that help us most effectively manage the care of difficult patients.

When Clinicians Disagree

June, 2007

Case:
Mrs. J. was a 73 year old woman with rheumatic valvular disease, severe tricuspid regurgitation, moderate aortic stenosis, and severe mitral valvular regurgitation status post St. Jude’s prosthetic artificial valve in 1986. The patient also had pacemaker placement for bradycardia in July of 1997 and on Coumadin for chronic atrial fibrillation.

In March 1999, the patient was hospitalized with two week history of malaise, fevers, chills, as well as a ten pound weight loss, diarrhea and nausea. The patient had noted a slow increase in shortness of breath during this time, but had been able to work until the day prior to admission. One day prior to admission the patient had noted a sudden increase in her difficulty breathing. On admission she had a reduced pO2 on 10 liters per minute of oxygen by face mask, marked jugular venous distension, a prominent holosystolic murmur heard throughout the precordium and back, cool extremities, and an elevated white blood cell count.

An urgent transthoracic echocardiogram showed dehiscence of one-quarter of the circumference of her mitral valve with a visible mobile vegetation. Blood cultures were drawn, empiric antibiotics were started, and a cardiothoracic surgery consultation was obtained. Given the patient’s severe hypoxia, hemodynamic instability, and likely future surgical intervention, the patient was intubated, underwent placement of an intra-aortic balloon pump, a Swan-Ganz catheter, and an arterial line. The patient was also started on pressors. At that time her admission laboratory data returned showing acute renal failure as well as some signs of early liver dysfunction.

After prolonged consultation with cardiothoracic surgery, the patient’s preoperative mortality risk, as well as likely post-operative morbidity, were determined to make her an unacceptable surgical risk. Therefore, the decision was made to attempt to medically optimize her situation with the treatments outlined above in hopes that she could eventually go to surgery in a few days. This decision was made in consultation at length with the family who wished at that time to pursue all possible routes towards protecting their mother’s life. There was some discussion between the members of the various consulting teams as to whether or not this course of action was appropriate. Some felt that surgical treatment was the only definitive solution to this patient’s severe mitral valvular dehiscence, whereas others felt that medical optimization could perhaps provide her with the option of undergoing surgery in the future.

There were strong disagreements not only between services but even within the teams on each service. In these circumstances it became difficult to agree on a course of action but to determine whose opinions and preferences would be decisive.

OBJECTIVES:

To acknowledge that experts can disagree.
To better understand the basis of professional disagreement.
To examine several strategies for making contested decisions.