Bioethics Committee Project

Chrissy Ramos, Jonathan Rodriguez, Shima Shiehzadegan, Sarita Smith, Bryan

Vargas and Amanda Whittle
Case
A forty-five-year-old man with a three-year history of cardiovascular disease has entered the hospital with a stroke that has paralyzed his
right side and caused him to aspirate food of any consistency. His mental status is clouded and there is disagreement as to whether or
not he has decisional capacity. His language capacity is only “yes” and “no,” and his responses are inconsistent. The attending physician
is convinced that the patient has lost decisional capacity while two family members are equally convinced that he has decisional
capacity. The patient’s wife and two other children are ambivalent about his competency to make decisions. The prognosis for recovery
of safe swallowing and speech approaches zero because of the dense damage to the cerebral cortex visible on brain imaging. Two
neurological consultants have verified that recovery is likely to be minimal and that permanent, severe disability will be the outcome.

The patient does not have an advance directive. The patient’s wife says that they never did discuss his preferences about life-sustaining
treatment. She is convinced that he would not want to live in this disabled condition, but is uncertain whether to request the placement of
a feeding tube. Two of her four adult children are strongly opposed to the tube placement, while the other two insist that not to do so
would be to “kill our father.” The patient’s wife is torn between these two positions.

The attending physician and the rest of the treatment team are opposed to placing the feeding tube. Their argument is that the patient
has “minimal consciousness” and will not improve. They define this as a futile situation with no reasonable expectation of recovery.
Furthermore, two nurses claim that during previous hospitalizations for episodes of cardiovascular events the patient told them that he
would not want to be sustained by artificial means — not by ventilators, renal dialysis, or tube feeding. It is their position that the patient
has expressed his preference to not be kept alive in a futile situation.
Summary of Case
● A 45 year old man with a three-year history of cardiovascular disease has come into our care due to experiencing a stroke that
paralyzed his right side. In return, this has caused him to aspirate any type of food.
● The patient's’ mental status is minimal; his language capacity is only “yes” or “no” with inconsistency
● Physicians state that the patient has lost decisional capacity
● His prognosis for recovery in regards to safe swallowing and speech has approached little to none and two neurological
consultants have verified that the damage is severe permanent disability.
● The patient does not have an advanced directive and has never discussed his preferences regarding life-sustaining treatment
with wife or children.
● Wife is unsure whether to place a feeding tube
- 4 children are opposed to placing the feeding tube
- 2 children insist that if a feeding tube is not in place then they would be killing their father
● Physicians are opposed to placing the feeding tube as well because the patient has minimal consciousness and define the
circumstance as a “futile situation with no reasonable expectation of recovery.”
● 2 nurses that have previously cared for him in the past share that the patient once expressed he would not want any life-
sustaining treatment such as ventilators, renal dialysis, or tube feedings.
Patient
● Role:
○ Mental Status is minimal, language is limited to “yes” and “no”
with inconsistency
○ No advance directive in place
○ No decision making capacity (determined by the physician)
● Recommendation:
○ Despite not having an Advanced Directive he expressed his
wishes to nurses during previous hospitalizations (no artificial
life sustaining treatments)
● Perspective:
○ Interventions will be futile and have no benefits
○ Will prolong the inevitable
○ Not a quality of life he wanted
● Ethical Theory:
○ Autonomy: Honoring the patient's decision
○ Nursing Code of Ethics: 1.4 The Right to Self Determination
 Family Members View Recommendation:

● Family is concerned with wanting to do what is in

the patient’s best interest for his care, currently
Family Situation:
split on whether to place the feeding tube or not
● Wife: Convinced her husband does not want to live in this disabled state, does ● Request a second opinion regarding assessment
not know if feeding tube should be placed or not for nutritional support since of patient’s decisional capacity
he is unable to swallow
○ Two children: Support placing the feeding tube and believe not doing so Ethical Theories:
would be “killing” their father
○ Other two children: Strongly oppose placing feeding tube since ● Beneficence: Family should make decisions
healthcare providers have deemed the intervention as medically futile based on the best interest of the patient to
promote their overall well-being
Perspective:
● Non-maleficence: Refrain from causing
● Patient is unable to make own decisions regarding care, did not complete intentional harm to patient
advanced health care directive to make personal wishes known and did not ● Autonomy: Protect patient autonomy and right
discuss his preferences about life-sustaining treatment with wife to make own decisions about care, avoid allowing
family’s desire to override what patient would
○ Ideally, the family members perspective for making healthcare
decisions for their loved ones should follow the best interest standard want in the situation and reassess patient
decisional capacity
Bias:

● Family members may unintentionally make decisions for the patient based on
own emotions rather than the patient’s wishes
○ Two children may have personal difficulty accepting father’s
prognosis/losing him
Role: Provider
● Prognosis/Perspective: Patient has minimal consciousness and placing a g-tube will not
improve outcome. His right side hemiplegia is resulting in food aspiration of any consistency.
Poor prognosis.

● Bias: In the best interest of the patient without emotion. Based on prognosis.

● Recommendation: Oppose placement of g-tube because it will be futile with no reasonable

expectation of recovery. In episodes of consciousness would recommend completing of an
advance directive.

● Ethical Theory:
○ Non-maleficence: to not cause harm
○ Beneficence: the act of compassion and in the best interest of the patient.
● Hippocratic Oath- Modern Version
○ I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and
therapeutic nihilism.
■ Overtreatment- providing treatment when the outcome has no benefit
○ I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the
person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for
the sick.
(Edelstein, 1943)
Role: Nurse
● Nurse’s role: To help manage physical needs, prevent illness, and treat health conditions through
intervention and advocacy.
● Prognosis/perspective: Patient has poor prognosis due to right-sided hemiplegia and dysphagia
● Bias: towards the previous two nurses that were involved in the patient’s care and towards the rest
of the medical team.
● Recommendation: Speak to the two children and mom. Using therapeutic communication state the
risks of the feeding tube and why the healthcare team believes this will not improve his current
status in clear and concise terminology. Encourage family to spend as much time as possible with
father. Get order for swallow test and monitor decisional capacity of patient with family present.
● Nursing Code of Ethics: 1.1 respect for human dignity , 1.2 relationships with patients, 3.5 protection of patient health and
safety action on questionable practice, 4.3 responsibility for nursing judgements, decisions, and actions
● Ethical Principles: beneficence: to prevent harm to the patient , justice, autonomy, quality of life.
● Ethical Theory: Rights theory → Although the patient has limited decisional capacity, the patient still has rights and he must be
properly advocated for.
Role: Social Worker
● Role: Advocate for patients’ rights
○ Psychosocial and emotional support to patient and family

● Perspective: psychosocial

● Bias: interest of patient/or family but may lack medical knowledge

● Recommendation:
○ Meet patient needs first-comfort care
○ Provide support and education for family members
● Ethical Theory:
○ NASW code of ethics:
■ 1.01 Commitment to Clients
■ 1.14 Clients Who Lack Decision-Making Capacity
■ Value: Dignity and Worth of the Person (National Association of Social Workers, 1999)
Recommendations
● Oppose placement of g-tube because it will be futile with no reasonable expectation of recovery.

● In episodes of consciousness would recommend completing of an advance directive.

● Provide emotional support and education to family.

● Continue to monitor patient for palliative care/ end of life comfort measures.
References
Beauchamp, T.L. & Childress, J. F. (2013). Principles of biomedical ethics (7th ed.). Oxford
Press.
Fowler, M. (2015). Guide to the Code of Ethics for Nurses. (2nd ed.). American Nurses
Association.
Edelstein, L. (1943). The Hippocratic oath: Text, translation and interpretation. Baltimore:
The Johns Hopkins Press.
National Association of Social Workers. (1999). Code of ethics of the National Association of
Social Workers. Washington, DC. NASW Press.