47. CASE: Collegial Responsibilities

You are a pediatric critical care specialist working in the ICU taking care of a newborn infant who suffered a severe, prolonged reduction in blood flow to his brain at the time of birth. The consulting neurologist has indicated that the infant’s prognosis for functional neurological recovery is very poor in the unlikely event that he survives the next few days.  You and the neurologist have spoken at length with the parents about the grim prognosis. They have decided that withdrawal of intensive care modalities and the initiation of optimal palliative care are consistent with their values. They have requested a day to hold their baby and to allow extended family to come and be with them prior to stopping the mechanical ventilation.
You have now gone home after handing the case over to a physician colleague who is on call for the unit that night, explaining that the family will notify staff when they are ready to withdraw life support.

You receive an agitated call from the ICU charge nurse at 2 am, as the family has requested life support to be discontinued but she is refusing to write an order for this, saying that she knows nothing about it. The parents are very distressed about this turn of events.

[Modified version of a case authored by Alixe Howlett]

  • What are the boundary issues, if any, in this case?         
  • Are there issues with communication between team members?
  • How should this be addressed?         
  • How should you deal with this situation when receiving the call at 2 am?         
  • Who should be involved in deciding next steps?

Some Values and Ethics Issues to Consider

  • Compliance with policies and procedures
  • Respect for professional integrity
  • Patient-provider relationships
  • Trust
  • Respect for patient autonomy
  • Respect for dignity
  • Patient-family relationships
  • End of life decision-making
  • Patient-centered care
  • Professional boundaries
Advertisements

10. CASE: At a Crossroads…

Sandra Livingstone, age 45, was admitted to the hospital with diffuse ischemic encephalopathy – a very significant, global brain injury – secondary to sustaining a massive stroke at home. It is now ten months after her admission. Ms. Livingstone is on an acute internal medicine unit where she has been living since her discharge from the intensive care unit.

She is unable to communicate with others and appears to be in profound distress, spending much of her time screaming and obstructing the attempts of nurses to care for her. She is unable to eat and drink due to neurological damage to her swallowing mechanism. She has just managed to remove her J-tube for the fourth time despite being in arm restraints and having her hands padded on a twenty-four hour basis. Trials of various medications to target her intense agitation have been unsuccessful.

The consultant neurologist, Dr. Bailey, recently reassessed Ms. Livingstone. In his opinion, her neurological status is now stable and the prognosis for further neurological recovery is extremely low. He comments that “this is the way she will always be”.

Ms. Livingstone had not made a personal/ advance directive prior to her stroke. Her statutory decision-maker is her father, Mr. Livingstone, a person of strong religious faith. He believes that his daughter is “still in there” and that she will eventually recover sufficiently to allow him to take her home. He refuses to discuss the possibility of withdrawing life-sustaining treatment, i.e., her J-tube.

The clinical unit’s social worker, Mr. Roberts, has been exploring alternative residency options for Ms. Livingston. Given her current health status and long term, significant care requirements, Ms. Livingstone cannot be formally classified for placement in a continuing care facility. Her local rural hospital has declined to accept her for care through a transfer from the tertiary care centre.

A health lawyer from Legal Services and a clinical ethics consultant are asked to participate in a health care team conference to explore potential ways forward.

  • What issues should be discussed at this meeting?
  • Which of these issues are ethics issues?
  • What decisions need to be made?
  • How should the decision-making be prioritized?
  • What resource allocation and policy issues in this case have ethical implications?

Some Values and Ethics Issues to Consider

  • Substitute decision-makers
  • Capacity
  • Compliance with policy
  • Spirituality/ religious beliefs
  • Patient-family relationships
  • Respect for human dignity
  • Quality of life
  • Resource allocation