CASE STUDY
CASE 1--MRS. S
Mrs S. was admitted to an SNF two years ago after a stroke left her paralyzed on the right side. She also had mild aphasia which cleared completely with the help of speech therapy but very little functional recovery of the arm or leg. At the time of admission she made it clear that she was optimistic about the future, that she believed in the Biblical instruction to "choose life" and would accept all offered care. She refused to sign any advance directive. She stated that in the first few days after her stroke there had been concern over her ability to swallow and that she would have accepted a feeding tube if that had been necessary. Mrs. S. has two adult daughters, both of whom visit their mother regularly. The two daughters are both very quiet, clearly still dominated by their powerful mother who remains forceful despite her age and infirmity.
Two months ago Mrs S. began to complain of back pain which quickly became excruciating. Despite a stoical personality she begs for powerful analgesics, finally achieving partial pain control with substantial doses of morphine. While awaiting the results of a CAT scan, she sustains a shower of emboli to the brain leaving her confused and unable to speak. A CAT scan of her head also shows lesions in the visual areas suggesting she is probably unable to see. The formal reading of her abdominal CAT scan is that she has a large, inoperable pancreatic cancer invading posteriorly into the muscle and bone of the back. The Oncology consultant states that there is no effective treatment for her condition and that she has less than six months to live, regardless of treatment. Mrs. S has been losing weight and may have difficulty swallowing. She lies in bed, grimacing and moaning.
The attending physician proposes a feeding gastrostomy. He points out that the patient has always wanted the maximum done and specifically said she would have consented to one in the past. Her daughters request a meeting of the Ethics Committee. They beg for measures to make their mother comfortable and not to prolong a painful dying process which is torturing her and them. They point out that their mother was never faced with a situation like she faces now, could not have envisioned the pain, and that nothing in her religion requires her to extend her period of suffering when death is inevitable.
Source: NYCLTCEN Conference entitled "When the Unexpected Happens: Interpreting Advance Directives in an Imperfect World," June 10, 1999 at St. Vincents Hospital and Medical Center, NYC.
