Case 1:
An 80-year-old man in a coma, with no hope of recovery, is admitted to an LTC facility where you are employed as a healthcare administrator. The man has not prepared an advance directive such as a living will or a healthcare proxy. The patient’s religion does not require artificial nutrition or hydration, and all members of the patient’s family agree that the patient does not want to die with tubes attached to him. The attending physician has met with the family prior to completing the POLST form to determine what orders he will write. The physician informs the family that the patient will die in a few days without having a feeding tube inserted for water and liquid food. The feeding tube may keep him alive for a number of years. If there is no feeding tube for hydration, his death might be painful or uncomfortable. The physician and the facility’s religious affiliation would prefer to treat the patient with artificial hydration via a feeding tube rather than do nothing. The family has refused the feeding tube, and the physician has referred the matter to the institution’s ethic committee.
Questions:
1) As a member of the healthcare ethics committee, explore the following options,
A. Transfer the patient to an inpatient hospice, where he can die a natural death and any pain will be treated with medications.
B. Keep the patient at your facility and go to court for an order to insert a feeding tube under the contention that, without the feeding tube, he will die.
2) Discuss how keeping the patient at your healthcare institution or having this physician treat the patient would violate the religious stance of both the organization and the physician.
3) How is this discussion changed if the patient has both a living will and a healthcare proxy that specifically state he does not want a feeding tube and he wishes his death to be peaceful, even if that means using medications to keep him comfortable at the expense of shortening his life?
CASE 2:
A 35-year-old woman with chronic disease is admitted to your LTC facility. She has developed a problem requiring a transfusion, and if she does not receive one, she will die. Her religious beliefs preclude her from receiving blood products. After a thorough explanation by the physician, she understands that she is likely to suffer permanent physical injury and possibly die if she refuses to accept the transfusion. Her family, which shares the same religious affiliation, supports her decision. The physician refers the matter to the healthcare ethics committee on which you sit as the healthcare administrator. The committee members all agree that the law permits a competent adult to refuse medical care.
Questions:
1) Is it ethical to speak to his patient in private, away from the family, and offer her the option of a secret transfusion so that nobody knows of it, or is this coercion into sinful behavior?
2) Is it ethical to meet with the family and the patient to attempt to convince them to change their minds regarding the transfusion? What can and should be said to them? What should not be said?
3) How does this discussion change if the patient is a child or a ward of the state?
4) What are the legal facts of which the healthcare administrator must be aware in such a case?