48. CASE: Shared Experience

You have recently started working as an RN in cardiology at the local pediatric health centre. One of the first cases you are involved with hits a little close to home. It involves a 2-year old patient named Kira who has a congenital cardiac abnormality. The clinical circumstances are similar to what you experienced with your son, Bradley, about four years ago. Bradley spent several weeks in hospital for investigations and you and your partner were faced with a difficult decision about whether to proceed with cardiac surgery. With some understandable trepidation and anxiety, you and your partner agreed to the surgery and Bradley came through it just fine. However, given the nature of the cardiac abnormality, you know how easily it could have turned out differently. You now see Kira’s parents faced with the same difficult choice. They are struggling with what decision to make and are very anxious.

  • Should you discuss your own experience with Kira’s parents?
  • If so, what might you choose to disclose?
  • What biases might you contribute to the situation – should you try to minimize their influence?
  • How will you balance your professional expertise and personal experience?

Part 2

It is about a year later and you run into Kira’s parents in the hallway outside the cafeteria. They have just come from the parents’ bereavement group and are having a tough time living without their daughter. They are organizing a charity event in their community to celebrate their daughter’s life and to generate funds for the pediatric cardiology program. Both parents express how much they would appreciate it if you came to the event and spoke at it in the capacity of one of the individuals who cared for their daughter. The event is scheduled for six weeks from now and the parents indicate that they need to know as soon as possible whether you can participate.

Should you go to this event? If so, should you be a speaker? 

Some Values and Ethics Issues to Consider

  • Compliance with policies and procedures
  • Respect for professional integrity
  • Patient-provider relationships
  • Honesty, trust and truth-telling
  • Overlapping roles and responsibilities
  • Family and community relationships
  • Professional boundaries

27. CASE: Withdrawal of Life-Sustaining Treatment

Mr. Windown, age 82, is admitted to a cardiology clinical unit with unstable angina. In addition to his coronary artery disease, Mr. Windown suffers from disabling generalized osteoarthritis, chronic and progressive obstructive lung disease, and diabetes with associated compromise of his vision and kidney function.

The coronary angiography reveals significant blockages of Mr. Windown’s coronary arteries. His attending cardiologist recommends that he undergo urgent four-vessel cardiac bypass grafting (to shunt blood around the blockages). The consultant cardiovascular surgeon, Dr. Paterna, gets Mr. Windown to sign a consent form for the procedure and mentions that it is anticipated that Mr. Windown will need to spend two days in the Cardiovascular ICU after the surgery.

In the past year, Mr. Windown’s health status has deteriorated to the extent that he can no longer perform any physical chores on his hobby farm. Prior to developing unstable angina, he was limited to walking around the first floor of his farmhouse and watching TV. After giving considerable thought to his future health care and treatment, Mr. Windown named his daughter, Elle, as his delegate in a personal directive, which does not provide any specific instructions. In a general, frank discussion about his health, Mr. Windown clearly expressed to his wife and Elle that he did not wish to be maintained on life support for a prolonged period of time.

Unfortunately, Mr. Windown experiences a significant complication from his cardiac bypass surgery – he suffers an intra-operative stroke, which renders him incapable of making health care decisions on his own.

Two and a half weeks after the surgery, Elle speaks to Dr. Paterna (who is now her father’s attending ICU physician) and requests that her father’s life sustaining treatment (including mechanical ventilation and renal dialysis) be withdrawn. Dr. Paterna gets annoyed with Elle, describes Mr. Windown’s health status in highly technical terms, and emphatically informs her that, in his opinion, her father has a reasonable chance of recovery to a functional status similar to the one he has experienced for the past year. Dr. Paterna tells Elle that this recovery will require another two to four weeks in the ICU and that he is uncomfortable with withdrawing Mr. Windown’s life sustaining treatment at this time.

When Elle insists that her father’s prior, verbally-expressed wishes be respected, Dr. Paterna manages to put her off for a few days by not responding to her request for a family meeting. He complains bitterly in the staff room that Mr. Windown’s family is being “difficult”. With the encouragement of the ICU’s assertive social worker, Dr. Paterna reluctantly agrees to consult ethics.

  • How would you proceed with this consult?
  • Is this a communication and/or professional practice issue or an ethics one?
  • Identify any underlying ethical tensions in this situation?
  • Is Dr. Paterna right to push back on Elle’s request?

Some Values and Ethics Issues to Consider

  • Advance care planning and personal directives
  • Substitute decision-making
  • Respect for professional integrity
  • Respect for patient autonomy
  • Respect for human dignity
  • Patient-provider relationships
  • Patient-family relationships
  • Quality of life
  • Consent