Case Studies – Barney Says No
Case Studies:
Barney Says No
Determining the Appropriate Surrogate and the Goals of Care
Almeda was an eighty-four-year-old woman who lived a retiring life with no family and few friends. She suffered a disabling stroke three years ago and has been confined to bed in a nursing home.
Almeda has lost decisional capacity and left no advance directives. Barney, her long time friend, has been her unofficial substitute decision maker. Almeda has developed a stage IV sacral decubitus, now colonized with multiple resistant staphylococcus areus and pneumonia with heart failure. She is now in the intensive care unit.
For two weeks, Alameda has been on the ventilator and fed with a gastric feeding tube. During this time she as been treated with high dose cardiovascular drugs and Vancomycin antibiotic. There has been no progress in the heart failure or pneumonia. Although stoic, Almeda shows clear signs of pain when moved about for care.
The nurses and attending physician have approached Barney on numerous occasions to raise the question about stopping aggressive curative treatment and moving toward palliative care.
Barney has always insisted that he sees more potential in Almeda’s condition. When asked what the right goal for Almeda ought to be, he answered, “It would be good if she could sit up and watch a little television.”
Almeda’s renal function has now become seriously impaired with a serum creatinine rising to levels requiring renal dialysis. With the prospect of dialysis, the nursing staff asked for a meeting with the attending physician and Barney to discuss treatment redirection from curative to palliative care.
Questions for discussion
Use the following questions as guides in discussing the ethical implications of the preceding case.
• Does it make a difference which stakeholder raises the question about treatment redirection? What would have happened if Barney had raised objection to the course of treatment? The nurses, doctors, or Almeda herself?
• Does the absence of advance directives complicate or simplify the treatment redirection process?
• Is Barney an appropriate substitute/surrogate decision maker to consent to treatment redirection to palliative care?
• Should some “official” or “legal” action be taken in order to proceed with a treatment redirection process?
• What would Almeda prefer if she were able to contribute to the discussion?
• Is Barney’s statement of a goal for Almeda adequate to justify continuing aggressive curative treatment?
• Is there evidence from the case text that the attending physician has been active enough in trying to inform and persuade Barney to consent to treatment redirection?
• What should have been the point of view of the nursing staff if Almeda was slowly getting better? What if she were neither improving nor getting worse?
• What is it about the prospect of renal dialysis that stimulates the raising of the treatment-redirection process? Why not when the gastric tube was inserted? Or when the ventilator was started?
Expert Solution Preview
Introduction:
This case study presents a scenario where a patient with limited decision-making capacity is receiving aggressive curative treatment despite a lack of progress. The patient’s surrogate decision-maker, a friend, is resistant to switching to palliative care and has set an unrealistic goal for the patient’s recovery. The nursing staff has raised the question of redirecting treatment to palliative care, but the surrogate decision-maker is not in agreement. This ethical dilemma raises various questions regarding the appropriateness of the surrogate decision-maker, the absence of advance directives, the role of healthcare professionals in communication with families, and the definition of aggressive curative treatment.
1. Does it make a difference which stakeholder raises the question about treatment redirection? What would have happened if the surrogate decision-maker had raised objection to the course of treatment? The nurses, doctors, or the patient herself?
The stakeholder who raises the question of treatment redirection does make a difference since it influences the decision-making process. The surrogate decision-maker plays an important role in this process since he or she is responsible for making decisions on behalf of the patient. In this case, the surrogate decision-maker is resistant to redirecting the focus of treatment and is setting an unrealistic goal for the patient’s recovery. If the surrogate decision-maker had raised objection to the course of treatment, it would have required a reassessment of the patient’s condition and the appropriateness of aggressive curative treatment. If the nurses, doctors, or patient herself had raised the question of treatment redirection, it would have allowed for a collaborative decision-making approach in the best interest of the patient’s overall well-being.
2. Does the absence of advance directives complicate or simplify the treatment redirection process?
The absence of advance directives complicates the treatment redirection process since it places the decision-making process in the hands of the surrogate decision-maker. In this case, the surrogate decision-maker is setting unrealistic goals for the patient’s recovery, which goes against the medical advice of healthcare professionals. Advance directives provide a clear understanding of the patient’s wishes in situations that require surrogate decision-making. The absence of advance directives places a burden on the surrogate decision-maker to make decisions that align with the patient’s values and beliefs, making it challenging for healthcare professionals to redirect treatment.
3. Is the surrogate decision-maker an appropriate substitute/surrogate decision maker to consent to treatment redirection to palliative care?
The surrogate decision-maker may not be an appropriate substitute decision maker in this case as they are not acting in the best interest of the patient. The surrogate decision-maker is setting an unrealistic goal for the patient’s recovery, which goes against the medical advice of healthcare professionals. The surrogate decision-maker should be making decisions that align with the patient’s values and beliefs in situations where the patient cannot make decisions for themselves. The healthcare team should communicate with the surrogate decision-maker to assess their understanding of the patient’s condition and clarify what aggressive curative treatment entails. If the surrogate decision-maker is still resistant to redirecting treatment to palliative care, the healthcare team can explore other avenues of care.
4. Should some “official” or “legal” action be taken to proceed with a treatment redirection process?
In situations where surrogate decision-makers are resistant to treatment redirection to palliative care, it may be appropriate to seek legal consultation. This can involve a review of state or federal laws regarding end of life care. However, such actions should be viewed as a last resort, and healthcare professionals should attempt to collaborate with the surrogate decision-maker to reach a satisfactory conclusion.
5. What would the patient prefer if she were able to contribute to the discussion?
If the patient were able to contribute to the discussion, it would be important to assess her values and beliefs to make decisions that align with her wishes. If the patient had advance directives, healthcare professionals could use them to guide her care. In the absence of advance directives, healthcare professionals should consider her quality of life and comfort when redirecting treatment to palliative care.
6. Is the surrogate’s statement of a goal for the patient adequate to justify continuing aggressive curative treatment?
No, the surrogate’s statement of a goal for the patient is not adequate to justify continuing aggressive curative treatment. The surrogate’s goal for the patient’s recovery is unrealistic and places the patient at risk of unnecessary harm. As healthcare professionals, we have a responsibility to provide compassionate care that aligns with the patient’s values and beliefs.
7. Is there evidence from the case text that the attending physician has been active enough in trying to inform and persuade the surrogate decision-maker to consent to treatment redirection?
There is no clear evidence from the case text that the attending physician has been active enough in trying to inform and persuade the surrogate decision-maker to redirect treatment to palliative care. The text suggests that the nursing staff has raised the question of treatment redirection, but the surrogate decision-maker is resistant. The attending physician should communicate with the surrogate decision-maker to assess their understanding of the patient’s condition and clarify what aggressive curative treatment entails. The healthcare team should emphasize the importance of redirecting treatment to palliative care to align with the patient’s values and beliefs.
8. What should have been the point of view of the nursing staff if the patient were slowly getting better? What if she were neither improving nor getting worse?
If the patient were slowly getting better, the nursing staff should assess the patient’s quality of life and make decisions that align with the patient’s values and beliefs. The healthcare team should communicate with the surrogate decision-maker to reassess the patient’s goals for recovery. If the patient were neither improving nor getting worse, the healthcare team should assess the patient’s well-being and consider redirecting treatment to palliative care.
9. What is it about the prospect of renal dialysis that stimulates the raising of the treatment redirection process? Why not when the gastric tube was inserted? Or when the ventilator was started?
The prospect of renal dialysis stimulates the raising of the treatment redirection process since it is an invasive and intensive procedure that can place the patient at risk. The healthcare team should assess the patient’s overall condition and consider redirecting treatment to palliative care to reduce unnecessary harm. When the gastric tube was inserted or the ventilator was started, the patient was not at such a high risk, and the healthcare team may have viewed these treatments as potentially beneficial. However, if these treatments were causing more harm than benefit, the healthcare team should reassess the patient’s goals for recovery and consider redirecting treatment to palliative care.
