Case study1

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 substitute decision maker for a patient who has lost decisional capacity is adamant about continuing curative treatment, despite the absence of progress and the patient’s probable preference for palliative care. The ethical implications and complexities surrounding treatment redirection from curative to palliative care are discussed in the following answers.

Answer:
The stakeholder who raises the question about treatment redirection does make a significant difference. If Barney had raised the objection to the course of treatment, it would carry more weight than if the nurses, doctors, or Almeda herself had raised the issue. As an unofficial but long-time substitute decision maker, Barney has the responsibility to act in the patient’s best interest. Any objection raised by him to the continuance of curative treatment should be given serious consideration, and the medical team should consult with him to arrive at a solution that aligns with Almeda’s best interests.

Answer:
The absence of advance directives complicates the treatment redirection process, as the medical team must rely on substitute decision makers or their understanding of the patient’s values and wishes to make decisions. This lack of clarity can create conflicts, as seen in this case, where the substitute decision maker’s goals may differ from what the patient may have wanted.

Answer:
Barney is not an appropriate substitute decision maker to consent to treatment redirection to palliative care as his goals for Almeda do not align with her wishes (as unknown). Barney’s insistence on continuing curative treatment despite the lack of improvement, and Almeda’s clear signs of pain when being moved, suggests that Barney may not be acting in her best interest. Therefore, the medical team may need to consider other factors to arrive at a decision that aligns with the patient’s best interests.

Answer:
Treatment redirection from curative to palliative care must be a joint decision made by the medical team and the substitute decision maker, if applicable. However, if the substitute decision maker is not acting in the patient’s best interest, and the medical team has concerns, they may need to seek legal guidance to ensure that the decision aligns with the law and ethics.

Answer:
If Almeda were able to contribute to the discussion, her preference would take precedence over all other considerations. However, as she has lost decisional capacity and left no advance directives, the medical team should consult with the substitute decision maker to make a decision that aligns with what is most likely to be Almeda’s wishes.

Answer:
Barney’s statement of a goal is not adequate to justify continuing aggressive curative treatment if the patient is not responding to it. The medical team should explore other options, such as palliative care, to ensure that the patient’s best interests are being served.

Answer:
The case text does not provide enough evidence to determine whether the attending physician has been active enough in trying to inform and persuade Barney to consent to treatment redirection. However, as medical professionals, it is their responsibility to ensure that the best interests of the patient are being served, and they should make every effort to communicate this to the substitute decision maker.

Answer:
The nursing staff should view the situation objectively and be guided by what is best for the patient. If Almeda is slowly getting better, they should continue to provide curative treatment. If she is not improving or getting worse, they should consider treatment redirection to palliative care.

Answer:
Prospect of renal dialysis stimulates the raising of the treatment-redirection process because it represents a significant escalation in the level of intervention required to maintain the patient’s health. By this point, the medical team may be concerned that the patient’s best interest is no longer being served by curative treatment and is favorable for palliative care. With the gastric tube and ventilator, it may be still possible for the patient to recover or improve, but renal dialysis represents a more invasive procedure.

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