Description of the Case Forgoing life-sustaining treatment
The book discusses a case on end-of-life care for a patient with advanced ovarian cancer
and anoxic brain damage. The family has consented to a Do Not Resuscitate order and wishes
for the patient to receive only comfort care, with artificial nutrition and hydration discontinued.
The nursing staff is troubled by this course of action, and the book highlights the ethical
challenges that arise when limiting life-sustaining treatment. The book emphasizes the
importance of respecting patient autonomy and family wishes, clarifying the medical and ethical
implications of withdrawing life-sustaining treatment, and involving the palliative care service in
end-of-life care planning. Bioethics consultation is recommended to address the difficult ethical
issues that arise in these situations and to support staff, family, and patients in the decisionmaking process.
Patients’ Perspective
The patient in this case, Mrs. Martel, is at the center of the decision-making process. As
a capable adult patient, she has a well-settled right to make an informed decision consenting to
or declining treatment, even if the decision results in death. However, in this case, Mrs. Martel
suffered significant anoxic brain damage and is currently comatose and unable to make
decisions for herself. In the absence of an advance directive, the family is often best suited to
represent the patient because of their long-standing and intimate relationship. In this case, Mrs.
Martel's family has provided letters attesting to the fact that she "would never want to live
connected to tubes," and they have consented to a DNR order and requested that Mrs. Martel
receive only comfort care. While Mrs. Martel had not executed an advance directive or
appointed an agent, her family agrees on what she would want in her current situation.
Ethically, there should be a presumption that the family's knowledge of and concern for the
patient is the best guide in making decisions for her end-of-life care. The care team should take
the family's wishes into account when making decisions about Mrs. Martel's care. The key issues
are whether the interventions are benefiting the patient or contributing to unnecessary
suffering and prolonging the dying process and whether the patient or surrogate believes they
should be forgone. In this case, the family has made the decision to forgo artificial nutrition and
hydration, which may prolong the dying process and cause unnecessary suffering. Overall, the
bioethical perspective in this case emphasizes the importance of respecting the patient's
autonomy, even in the absence of an advance directive, and considering the family's wishes
when making decisions about end-of-life care. The focus should be on maximizing comfort,
minimizing suffering, and not prolonging the dying process, which is in line with Mrs. Martel's
values and wishes as expressed by her family.
Families Perspective
From Mrs. Martel's family's perspective, the most important consideration is likely
honoring their loved one's wishes and ensuring that she receives care consistent with her
wishes. The family has presented letters attesting to the fact that Mrs. Martel "would never
want to live connected to tubes" and has consented to a DNR order and the cessation of
artificial nutrition and hydration. As such, the family likely believes that continuing lifesustaining treatment would not be in Mrs. Martel's best interest, as it would not align with her
expressed wishes and values. They may also be concerned about the potential for further
suffering and discomfort if treatment were continued unnecessarily. However, the family may
also be struggling with the emotional and psychological impact of making such difficult
decisions about end-of-life care for their loved one. They may feel guilt or sadness about the
prospect of removing artificial nutrition and hydration and may be struggling to come to terms
with the inevitability of Mrs. Martel's death. Bioethically, it is important to ensure that the
family is well-informed and supported in making decisions about Mrs. Martel's care. This may
involve providing them with information about the risks and benefits of various treatment
options and clarifying any misunderstandings they may have about the process of dying. It may
also involve providing them with emotional and psychological support, such as counseling or
spiritual care, to help them cope with the challenges of this situation. Overall, the bioethical
perspective from Mrs. Martel's family's point of view involves respecting their loved one's
wishes and values while also supporting them through the emotional and psychological
challenges of making end-of-life decisions.
Physicians Perspective
From the perspective of Mrs. Martel’s physician, the bioethical issues at play in this case
include patient autonomy, beneficence, non-maleficence, and justice. The physician has a duty
to respect Mrs. Martel’s autonomy and allow her to make decisions about her own medical
treatment. However, if the physician believes that Mrs. Martel’s decision to refuse treatment
will result in harm to her, the physician also has a duty to act in her best interest and promote
her well-being (beneficence). This creates a potential conflict between respecting Mrs. Martel’s
autonomy and promoting her well-being. Additionally, the physician has a duty to do no harm
(non-maleficence) and not provide treatment that could cause undue suffering or harm to the
patient. This includes respecting Mrs. Martel’s decision to refuse treatment if it is not likely to
cause harm. Finally, the physician must also consider the principle of justice and ensure that
Mrs. Martel’s is not being discriminated against or treated unfairly due to her age or disability.
To balance these competing principles, the physician may need to engage in a process of shared
decision-making with Mrs. Martel’s and her family, exploring the reasons for her refusal of
treatment and discussing alternative options that may be available to promote her well-being
while also respecting her autonomy. The physician may also need to consult with other
healthcare professionals, ethics committees, and legal experts to ensure that all relevant factors
have been considered and that a fair and ethical decision is made.
Assessment of the Plan of Care and Outcome
From a reasoned and principled perspective, the plan of care and outcome of this case
can be evaluated based on the principles of beneficence, autonomy, and justice. The decision to
withhold treatment and prioritize comfort care for Mrs. Martel was based on a well-reasoned
assessment of her condition and was intended to prevent unnecessary suffering and improve
her quality of life. This decision was made with Mrs. Martel's expressed wishes in mind, as well
as the input of her family and medical team. From an ethical standpoint, this approach is
consistent with the principles of autonomy and beneficence, as it respects Mrs. Martel's right to
make decisions about her own care and seeks to promote her well-being. Additionally, by
shifting her treatment towards comfort care rather than invasive treatments with little chance
of success, the plan of care also reflects a commitment to the principle of justice, which
emphasizes the fair distribution of healthcare resources. Overall, the plan of care and outcome
of this case appear to be both ethical and justified based on the consideration of principles and
values.
References
Post, L. F. (2021). Handbook for health care ethics committees (3rd ed.). Baltimore, MD: John
Hopkins University Press.