Identify key moral concepts in the care of patients near the end of life.
Describe the process of advance care planning and how it helps prevent moral conflicts over end-of-life care.
Examine the main types of advance directives and portable medical orders for end-of-life care and understand how they help guide treatment decisions.
Consider the relationship between general goals of care and speciic treatment choices near the end of life.
Identify continuing challenges in making and implementing end-of-life treatment decisions.
Joan Thompson, a nurse in the cardiology unit, requests an ethics consultation regarding the care of her patient Mrs. Mary Wilson. Seventy-eight-year-old Mrs. Wilson was diagnosed with congestive heart failure 4 years ago; her condition has worsened gradually since then. She was admitted to the hospital 2 days ago with symptoms of shortness of breath, recurrent chest pain, fatigue, and confusion. This is her third hospitalization in the past 6 months. Mrs.Wilson’s difficulty in breathing has persisted despite drug therapy, and Dr. Kelly, Mrs.Wilson’s cardiologist, is preparing to intubate her and provide mechanical ventilation. Mrs. Wilson has confided to Ms. Thompson, however, that she does not want to be on a ventilator again, and wants only treatments to relieve her pain and allow her to rest. Ms. Thompson has observed that Dr. Kelly is unwilling to discuss palliative care with his patients and to write do-not-attempt-resuscitation (DNAR) orders, and she is concerned that Mrs. Wilson’s wishes are not being respected.
Dr. F, an oncologist in a small community practice, has been asked by a pharmaceutical company to conduct early-phase clinical trials involving several new investigational chemotherapeutic agents that do not yet have FDA approval. These would be very small phase I trials, with the possibility of conducting some phase I/II and phase II trials in the future as well. The reimbursement he will receive for the research will substantially increase the income of his practice, provided that he is able to recruit and retain a sufficient number of subjects. “More importantly, though,” Dr. F thinks to himself, “I have so little to offer many of my sickest patients now. The best thing about doing clinical research is being able to offer them something new, that just might be their best hope.”
Dr. G treats patients with hemophilia. Although treatments have improved dramatically in recent years, hemophilia is a devastating, and devastatingly expensive, chronic disease. Because she has high hopes about promising experimental technologies, she also conducts research. She prides herself on the research partnerships she develops with patient–subjects who seek to contribute to the development of better treatments. Recently, however, she has received inquiries from patients with hemophilia from around the world who want to enroll in her research because the experimental interventions are provided free of charge. These patients tell her that they cannot afford standard therapies, and that enrolling in her research is their only hope for treatment. Dr. G is troubled by this reasoning, and discusses it with a colleague, who responds, “Lots of people enroll in research to get treatment.[…]
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