Ann C. is a 69-year-old African-American female with a past…
Ann C. is a 69-year-old African-American female with a past medical history of poorly controlled hypertension, diabetes, atrial fibrillation, and dyslipidemia who presented to the Emergency Department after being found unresponsive at home by her neighbor. No history could be obtained from Ann on presentation as she was only uttering incomprehensible sounds. Ann’s outpatient chart indicated that warfarin was one of her home medications. On physical exam she was noted to be hypertensive (210/99), bradycardic (heart rate of 50 beats per minute), and to be flaccid in all four extremities. There were coarse, wet breath sounds at both lung bases, suggestive of an aspiration event. Additionally she did not open her eyes to verbal command, but did withdraw from noxious stimuli (i.e., Glasgow Coma Scale of 7 out of 15). Laboratory evaluation was notable for a slight leukocytosis, mild acute renal failure consistent with volume depletion, and an International Normalized Ratio (INR) of 3.4. Electrocardiogram was remarkable only for left ventricular hypertrophy and nonspecific T-wave flattening. Non-contrast CT scan of the brain demonstrated that the patient had sustained a devastatingly large intracerebral hemorrhage that was supratentorial and extended into the lateral ventricles. There was mass effect from edema, but no evidence of herniation. Ann’s anticoagulation was quickly reversed with fresh frozen plasma (FFP) and a nicardipine drip was started for her hypertension. A neurosurgeon was consulted, who determined that the hemorrhage was not amenable to surgical intervention, and continued medical management in the intensive care unit was recommended. Based on available scoring methods for predicting prognosis, the neurosurgeon stated that Ann’s risk of inhospital mortality from the event approached 100 percent. Ann had lived at home for the 10 years prior to admission with her identical twin sister, Isabel. Both Ann and Isabel were well-known and liked by the medical team, since they always accompanied each other to well visits in the outpatient medical clinic and were always very pleasant. At the time of Ann’s admission, Isabel stated that Ann would never want “to be kept alive artificially using life support” per her own stated wishes in the past. However, Ann had never filled out a Living Will or designated anyone as her health care agent on a Power of Attorney for Health Care. To complicate matters, Ann had three adult children who lived out of state. They only spoke to Ann, on average, once a year by phone around the holidays, and none had ever spoken with their mother about end-of-life issues. When they were notified of Ann’s condition the two oldest children stated that they wished that Ann be kept alive on a mechanical ventilator, contrary to what Isabel stated about Ann’s wishes. They affirmed that they wanted “everything done” to try and save her life. When the youngest child was contacted, she stated that she did not know her mother’s wishes on this topic, but affirmed “I know that no one would want to be kept alive like that.” Ann’s condition continued to deteriorate. She was placed on a mechanical ventilator and remained a “full code” as per the wishes of her oldest children, since they were determined by the medical team to legally be Ann’s next of kin. Repeat CT of the brain several hours later showed expansion of the hematoma and new evidence of herniation. Despite optimal support Ann had an asystolic cardiac arrest shortly afterwards and attempts at resuscitation were unsuccessful. Explain the ethical issues that the medical team faces in this situation, based on the Principle of Beneficence, the Principle of Non-Maleficence, the Principle of Respect for Autonomy, and the Principle of Respect for Dignity. After you have briefly explained each of these ethical principles and how they apply, describe BRIEFLY what you would do in this situation and how you feel any legal issues might constrain or help you.
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