Ethical Dilemma Case

The Case of Anne R.

1st Situation
Your longtime patient, Anne R., is a relatively frail, 85-year-old woman who has lived more or less successfully at home since her retirement 20 years ago. Paul, her husband of 47 years, died 10 years ago. In many respects, she is still mourning his loss. Her life is generally solitary, inactive, and boring.
Anne has 2 daughters who live with their families in Houston and Toronto, both 3-hour plane rides away. They try to visit for holidays, and each daughter attempts to arrange to have her visit at least once a year. They seem to be a dedicated and loving family, albeit separated by nontrivial distance. However, Anne is increasingly reluctant to travel.
Anne has several maladies that you have been managing: atrial fibrillation; an arteriovenous malformation that causes occasional, and sometimes severe, gastrointestinal bleeding; chronic obstructive pulmonary disease; and osteoporosis. She has fallen twice but suffered only minor bruises.
Nine years ago, you partly convinced Anne of the importance of advance directives, although she winced and turned away when you raised the issue. In a designation of surrogate, she named both her daughters to make decisions for her if she became unable to do so, but she also declined to complete a living will. "I can't think about that right now," she said.
One night at 11:50, you receive a call from a hospitalist at General Medical Center, where you have privileges. Anne apparently had begun to feel very poorly and called 911. A workup in the emergency department showed atrial fibrillation. She is currently stable but uncomfortable. Her daughters do not yet know of this episode. You need to decide what to do.

What Should You Do?
Decision Point: Should You Go to the Hospital to See Anne?
Pro: You know Anne better than the doctors at the hospital do, and she is frightened and alone, with several comorbidities. You know it would be supportive and helpful to go, and you might be able to provide some information or help in some way.
Con: It is late and you're tired. You tell yourself that your presence would add very little. Anne could be transferred to the floor or admitted to the critical care unit, in the capable hands of others, until tomorrow.

*) Would you go to the hospital?

*) Would you wait until the next morning?



2nd Situation
Anne should probably be cardioverted, but this presents a small risk for stroke. You recommend the cardioversion and mention the stroke risk. Anne asks you to do whatever you think is best, so you order the procedure.
Normally, you would start prophylaxis against stroke with an anticoagulant, but Anne's arteriovenous malformation puts her at higher-than-normal risk for blood loss. You therefore decide against use of warfarin (or anything similar). You do not mention this to her, reasoning that she has already placed herself in your hands.
The cardioversion is successful, and at an office visit 1 week after Anne is discharged from the hospital, you broach the topic of implanting a pacemaker/defibrillator. She is very anxious and reluctant to undergo the procedure. You explain how the device works and how it is implanted. She is worried about the risks of the procedure; you are worried about the risks of not doing it.
There is a long-standing debate about whether physicians should discuss statistics with patients. Some prefer to make recommendations in the context of a trusting relationship. Others might cite the literature and ask the patient to make a decision. It is significant that every option poses risks, and these risks often need to be weighed against each other, not against a baseline or gold standard. Moreover, risks vary from patient to patient and -- perhaps most important -- can be very difficult to measure or determine.

Decision Point: How Do You Continue the Informed Consent Process?
Pro: Informed consent is not a courtesy, nicety, or risk-management stratagem. A foundation of medical ethics, the valid consent process requires that patients be given adequate information and have the capacity to understand and appreciate the information and make a voluntary decision. There is evidence to support the practice of robust communication: It leads to improved trust and better adherence to treatment regimens, for instance.
Con: The patient has already asked you to use your judgment. You believe you know what is best for her. There is no point in standing on ceremony, especially when it seems she simply does not want to hear at least some of what you might have to say. In any case, she is not incompetent, and no one is forcing her to accept the pacemaker/defibrillator.

*) Would you strongly recommend the defibrillator and mention but deemphasize the risks?

*) Would you be completely neutral, make no recommendation, and strongly encourage Anne to seek her daughters' advice?

*) Would you lay out the pros and cons equally and leave the decision to her, and if she doesn't make a decision, remind her in 2 months?



3rd Situation
Anne's living arrangements also pose some challenges. Because she lives alone, you're concerned about her getting help if she needs it. You ask her whether she has considered moving to an assisted living facility ("There is no way you're putting me in a nursing home with all those old people!") or moving in with one of her daughters ("I couldn't bear to be such a burden at my age"). You have now spent 20 minutes with her and are running far behind schedule.
Frustrated and a little annoyed, you ask her to call you in 2 weeks and recommend that she get an emergency medical alert bracelet. You also instruct one of your staff members to phone her in 1 week. At that time, she is fine and very grateful for the call; she keeps your aide on the phone for 10 minutes, chatting about the events of her day.
Three days later, at about 5 PM, you receive a call from a hospitalist at General Medical Center. Anne has had a severe myocardial infarction. She was found on her doorstep, apparently while picking up the daily newspaper. An untrained neighbor attempted cardiopulmonary resuscitation, and another summoned emergency medical services. She was resuscitated after 10-12 minutes of hypoxia/anoxia.
You arrive at the hospital a few hours later. Anne is in the intensive care unit (ICU). She is on a ventilator and receiving a variety of medications. She broke her hip during the fall and is also receiving opiate analgesia. A neurology consultation has been requested.
A social worker had seen that Anne's daughters are named as surrogates; they were contacted, and both arrive the next morning. You meet them in an ICU conference room. The consultant had determined that Anne's neurologic prognosis is bleak and that she is at best in a minimally conscious state. Her daughters are distraught. Both recall little about any conversations with her about end-of-life care, but one shared memory included Anne saying that she would not want to "live on tubes."
One daughter wants her to continue to receive full support. The other says she is ready for all nonpalliative treatment to cease and for her mother to die.

Decision Point: Do You Continue to Monitor the Patient and Work With the Family?

Pro: Of course. She is no less your patient now than before her myocardial infarction, and she will be your patient until she dies. Indeed, until a decision is made to terminate treatment, someone is needed to manage her treatments. Communication with family members continues to be an obligation of the professional physician.
Con: There is nothing more of substance for you to contribute medically. The daughters' disagreement puts you in a tight spot, and until they sort it out, there is nothing for you to offer. What is wanted now is some sort of end-of-life counseling, not competent medical treatment. Someone else needs to take over.

*) Would you accede to one daughter's wish to continue full support?

*) Would you oppose life support and strongly recommend, if not insist on, hospice?

*) Would you urge the daughters to reach an agreement?

*) Would you call the hospital lawyer or ethics committee?