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End of Life
Case 31 An Adolescent
with Cancer Who Wants to Discontinue Medical Treatment
**Participation
of a minor in medical treatment decision-making
**Determination of a
minor’s capacity to make medical decisions
**Conflict between
parents and minors concerning the course of treatment
Zach
is a 13-year-old boy who has osteosarcoma (cancer of the bone). He
presented with leg pain and after undergoing a course of preoperative
chemotherapy, he underwent segmental limb resection followed by
placement of an endoprostheis. This life-sparing surgery allowed him to
remain fully ambulatory, which was important because he was a fairly
active child. Three months later, however, he developed pulmonary
metastases, for which he underwent preoperative chemotherapy and
thoractomy (an operation to open the chest) with wedge resection of
three metastatic nodules in the left lung. His postoperative course was
complicated by empyema, (an infection between the lung and the chest
wall) for which he required chest tube drainage and antibiotics.
Zach
recovered from this setback but two months later developed a cough.
Diagnostic workup revealed bilateral pulmonary nodules and a mass
involving the tricuspid valve and papillary muscle (small muscles in the
heart that anchor heart valves). Despite two courses of doxorubicin (Adriamycin)
in the past, Zach has no evidence of clinical heart failure, so his
physician believes that further treatment, including surgery is possible
though its benefit is uncertain at best. At this time, Zach stated that
he does not want further treatment. “ I’m not going to get
better,” he asserted, “so why should I go through more
treatments?”
The oncologist explained to
Zach’s parents that the rapid tumor recurrence points to a poor
prognosis. Heart function is adequate but excision of the cardiac mass
would be essential before further aggressive treatment could be done.
The prognosis after bilateral pulmonary lesions is not as favorable as
after unilateral lesions. Even with treatment, Zach’s chances of
surviving another year are “very low.”
Zach has remained firm in
his wish to stop treatment, even after reviewuation and counseling from
both a social worker and psychiatrist. His parents comfort him but they
tell the oncologist that they are strongly in favor of treatment. The
oncologist gently reminds them that this is not what their child wants,
and that perhaps they should “try to let go.” “Are you saying
there is no hope?” asks his mother. “There is never no hope,” says
the doctor, “but we can’t dismiss the prognosis.”
The parents respond, “We
can’t let go. We want everything done for our son, even if there is
only one shred of hope.” Zach’s mother tearfully adds that she
wishes they had not allowed “that experimental surgery.” Zach is
their only child.
To what extent can this
13-year-old be involved in decisions concerning his medical treatment?
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Can the e3cision of this
13-year-old patient be honored despite the parents’ disagreement?
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What would be the place
of Zach’s wished if his prognosis wee less certain, or perhaps
even more favorable?
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How would the analysis
change if Zach’s parents were the ones who wished to stop
treatment, given the dismal prognosis, while Zach wished to pursue
whatever treatment options remained for him?
From: Ahronheim JC, Moreno
JD, Zuckerman C. Ethics in Clinical Practice, 2nd
Edition. Aspen Publication, Maryland, 2000
End of Life
12.
Dispute over DNR Status in a Patient Who Wants
Palliative
Surgery
**The
specificity of a DNR order
**Suspending DNR orders
during invasive procedures
**Physician interests and
obligations in the context of patients’ rights
**Insurance coverage
under managed care and hospice programs
Maria, a previously healthy woman, developed breast cancer at age 37.
Now, three years later, her cancer has metastasized to bone and pleura
(tissue covering which protects and cushions lungs). Further
chemotherapy or hormonal therapy is not expected to prolong her life.
She recently underwent pleurodesis to prevent recurrent pleural effusion
(outpouring of fluid). Her insurance carrier, a managed care
corporation, has a contract with a local home hospice program, and she
has recently enrolled. Prior to her enrollment in hospice, her bone pain
was poorly controlled. Hospice nurses have seen to it that Maria
receives sufficient doses of oral morphine, and her pain is fairly well
controlled.
Recently, Maria sustained a pathologic fracture of the hip. An
orthopedic surgeon in the emergency room explained that she may benefit
from reconstructive surgery for the hip, which could restore her ability
to walk. He further explained that he has performed this kind of
operation on hospice patients in the past. Maria was eager to undergo
the surgery, stating, “I want to die with my boots on.” On admission
requested a do-not-resuscitate (DNR) order, as she had done on a
previous admission when she was hospitalized for treatment of her
pleural effusion. To her surprise, she was informed that the DNR order
would be suspended while she was in the operating room, recovery room,
and surgical intensive care unit.
Her husband asked the surgical attending physician why this was being
done. The surgeon stated that this was the policy of the departments of
surgery and anesthesiology, and that it was adopted because their
“Hands would be tied” and they would be “unable to function”
without such a policy. The surgeon said that even if he himself agreed
to go along with the patient’s request, his department would not agree
and it would be impossible to find an anesthesiologist for the surgery.
“Besides,” He said, “things can go wrong, and if we just stand by
it would amount to killing your wife.”
Maria is uncertain about proceeding as planned under this restriction.
After another day goes by, the surgeon receives a call from the
hospital’s case manger, who informs him that the days that Maria waits
for surgery will be disallowed by Maria’s managed care company, and
the decision must be made quickly or Maria will have to be discharged.
What are the
justifications for performing an invasive procedure on a patient who
requests a DNR order?
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What are the ethical
implications of operating with a DNR order in place?
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If the surgeon insisted
that there be no DNR order during surgery, would this be a violation
of Maria’s rights?
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Is there a solution to
this dilemma?
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What if the patient
experienced intraoperative cardiac arrest related to sudden and
massive bleeding from a surgically damaged artery? From an artery
invaded by tumor?
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What limitations does
Maria’s hospice status place on her ability to obtain the surgery?
From: Ahronheim JC, Moreno
JD, Zuckerman C. Ethics in Clinical Practice, 2nd
Edition. Aspen Publication, Maryland, 2000.
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