Case Studies :
Case-Sam Addams
Sam Addams is a divorced 67 year old retired attorney with advanced liver cancer. After a long talk with his children and his primary care physician, Sam has decided that palliative care is his only realistic option. Although Sam would like to stay at home as long as possible, he wants the option of dying in a hospital when the time comes -both because he fears that his pain may become unmanageable and also because he isn't sure he wants his home "turned into a hospital." or that his two adult children can cope with the caregiving demands of his final days. Sam has Medicare Part A and Part B, as well as a supplemental policy through a commercial insurance carrier.
1. Will the Medicare hospice benefit give Sam access to the kind of care he wants?
2. What kinds of informal caregiving support resources are essential to his enrollment in hospice? What family system factors might influence this?
3. In order to avoid out of pocket expenses, what kinds of things will his personal supplemental policy need to provide? How likely is that?
Case-Kevin
Kevin is an unemployed 31 year old male with advanced liver failure and stomach cancer, secondary to alcoholism. Three months ago he lost his apartment due to his inability to pay the rent, and he is now living with his younger sister Florence. Kevin can now barely get himself to the bathroom and his level of pain is increasing. Florence would like to take care of Kevin over the course of his final days, but her limited income as a nurses aide is just enough to live on with no money left for her brother's care. On the basis of advise of friends, Florence has driven him to the local hospital E.R. and is now refusing to take him home. "I love my brother, but I can't continue to do this by myself with two young children that also need my attention." Placing yourself in the role of the E.R. social worker, investigate and explain the alternatives that are available to Kevin and his sister.
Case -Elmer Smith
Elmer Smith is a 78 year old retired grocer admitted to the Nooksack Valley Medical Center in a coma for what appears to be a devastating stroke. Elmer is now in renal failure, and a decision needs to be made concerning the continuation of dialysis. Elmer's physicians are divided on his potential for a recovery from his coma, though no one is optimistic. The choice is to either proceed with dialysis in the hope that Elmer will have some gradual return of consciousness, or to discontinue the dialysis and let him go. Elmer's physicians are now turning to you, the social worker, to gain a clear direction from the family.
Elmer's family is divided in their beliefs and preferences concerning the continuation of the dialysis. Elmer's wife, Ruth, would want everything done because "Elmer is a fighter". She also expressed the thought that she could not live with herself if she did not do everything possible to support his chances at life. Elmer's two adult children, a son and daughter are themselves divided. His son, Frederick, is developmentally disabled (I.Q. of 67) and wants to do everything to "save Daddy". Elmer's daughter Kathy is a nurse and clearly believes the situation is in fact hopeless in terms of recovery to a level of existence her father would find meaningful. In her view, she has already lost her father as she knew him. Kathy also believes if her father had all the information she has he would want to be let go. There is no directive to a physician available, although one year ago Kathy was given power of attorney for both of her parents so she could manage their affairs while they were on an extended trip. Kathy is also the legal guardian for her brother.
1. What public policy guides you in this situation?
2. What further information would you need to determine the appropriate course of action?
3. If your role includes the minimization of liability exposure to the hospital and medical staff, what would be your recommended course of action? Is this different from the course of action you would recommend from a bioethics frame of reference?
4. Of the above factors in this case, which are the most relevant to your determination of the appropriate course of action?
Case-Liz West
Liz is 17 years old, is five months pregnant, and until recently lived with her boyfriend Tom. She has now moved back to her parents' home after discovering her pregnancy, the event that also precipitated the break-up with Tom. Although her parents have given Liz the bedroom above the garage to live in and access to the house to cook meals and use the bathroom, Liz has been informed that as far as they are concerned she is not a part of the household and should not expect anything but a place to stay warm and dry. Liz has roughly $600.00 in savings, a job at a convenience store that pays the state minimum wage for 32 hours a week work and no benefits, and a car that is 12 years old and on its last legs. Liz has become increasingly depressed and hypertensive as her pregnancy has progressed, and she has no regular source of medical care.
1. What are the options to gain access to health care for Liz?
2. Which is most optimal?