Medical Futility - Overview This scenario highlights the ethical d...

ETHICAL Dilemma Medical Futility

STUDENT Worksheet

Mavis Anderson, 84 years old

Overview This scenario highlights the ethical dilemma of medical futility when Mavis remains in ICU on a ventilator as a result of respiratory failure. She also has dementia and terminal cancer. The family is unwilling to consider withdrawing life support and one of the members is openly antagonistic and is not afraid to question and confront nurses about what he thinks is best for his mother.

Clinical Dilemma Activity: STUDENT

• Scenario

History of Present Problem:

Medical Futility

Mavis Anderson is a frail, 84-year-old woman who was admitted to your medical unit six days ago after falling at home.She has a large hematoma on her right lateral hip. She is on warfarin daily for chronic atrial fibrillation. She has a history of stage IV breast cancer with metastasis to the liver, dementia, and COPD. Despite having only months to live, she is currently a full code. Mavis does not have a living will, but according to her son, who has the power of attorney (POA), she would want to live and wants everything done to support her.Ten days ago Mavis developed progressive SOB with respiratory failure that required intubation and mechanical ventilation. CXR confirmed bilateral infiltrates consistent with aspiration pneumonia. She continues to require ventilator support with vent settings of AC: 12, TV: 500, PEEP: +5, FiO2: 60%. Bipap weans have lasted only 15 minutes before she becomes tachypneic with RR >30 and O2 sat that drops to <90%.

Personal/Social History:

Mavis lives in a skilled long-term care facility and is widowed. She has six children who are actively involved in her care and live in the area. The oldest son, Tom, is POA.What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?RELEVANT Data from Present Problem: Clinical Significance: No living will.Son power of attorney (POA).Bilateral infiltrates consistent with aspiration pneumonia.Bipap weans lasted only 15 min. before she become tachypneic with RR >30 and O2 drops to <90% Requires ventilator support.Because patient does not have a living will, the son holds the power to make medical decisions on behalf of Mavis.Son will oversee medical decisions.Air spaces in the lung are filled with fluid.Patient not able to tolerate weans due to Patient is unable to breath on her. Related to respiratory complications.RELEVANT Data from Social History: Clinical Significance:

Has six children who are actively involved in her care.Patient has a lot of support when it comes to her care but it could also make decision making difficult when so many people are involved.

II. The Dilemma Begins…

Current Concern:

Palliative care was consulted and the physician documented the following:

• Mavis is critically and terminally ill with no chance of recovery to return to her prior living arrangement. She would require ventilatory support at a long term-care-acute-care (LTAC) facility with 24/7 nursing care. Despite this assessment, the son Tom who is POA continues to insist that full ICU support be continued that includes ventilator, vasopressors (neosynephrine), and parenteral tube feedings.• Mavis and her family are Catholic, and have faith and hope for a miraculous recovery which cannot happen unless Mavis is maximally supported in ICU. The son believes that removal of the ventilator support is akin to directly causing the death of his mother.• Palliative Plan: Care conference with all family members, medical providers and nursing. The current grim prognosis and recommendations of medical team will be presented.