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CASE 1: Mrs. Sakariye: Who is our patient?
24-year old woman from Somali whose labor is not going well but who adamantly
refuses a cesarean section.
CASE 2: Mr. Leary - Killing or allowing to die?
76-year-old man waiting for a nursing home placement who has a Keofeed tube in place.
CASE 3: Joe Jones – Providing futile therapy in the ICU?
Man with head and neck cancer who is in the ICU who wants everything to be done.
CASE 4: Sammy – Too young and too small?
Premature baby in the NICU whose parents are distrustful of the doctors and nurses.
CASE 5: Heather – Can we ‘give up’ on a kid?
7 year old who got very sick, very quickly and it is unclear if she will survive.
CASE 6: Mrs. Pearlman – would we be killing her or abiding by her
wishes?
Woman whose has been on TPN for 7 years and now is septic in the ICU.
CASE 1: Mrs. Sakariye: Who is our patient?
Mrs. Sakariye, a 24-year old woman from Somali, presented to the hospital in labor 18 hours ago
at approximately 39 weeks gestation. This is her first pregnancy and has been uneventful. She
obtained her prenatal care at a clinic within the university system. Mrs. Sakariye’s husband is
currently working and going to school. They hope and plan to return to Africa in the next 5 years.
Mrs. Sakariye speaks very limited English while her husband’s English is fairly good. She has no
family in the United States but has made several friends within the Somali community.
Since being admitted to the hospital, Mrs. Sakariye’s labor has progressed slowly. She is currently
3-4 cm dilated and 40% effaced. Fetal heart tones are being externally monitored. The baseline
fetal heart rate has been around 145 for most of the labor and has shown normal variability. At
about hour 18 and several times after that, the baby had some early decelerations to around 100
bpm (one reached 90 bpm but was associated with the need to reposition the external monitor
and hence was considered suspect by the labor nurse). After another hour she was at 5-6 cm and
60% effacement however the baby had several more episodes of early decelerations to 90-100
and is began to show late decelerations. Meconium staining was noted in the amniotic fluid
following these late decelerations.
The medical team recommended an urgent cesarean section due to the clinical picture of
relatively slowly progressing labor accompanied by probable fetal distress. They presented this
recommendation to the husband who translated the information to his wife. After a brief
discussion, the husband adamantly refused the C-section. Mrs. Sakariye also clearly and
repeatedly said “no” and shook her head. The team and labor nurse again explained the
urgency of the situation and the potential serious consequences to the baby. They had an
interpreter come to the patient’s room and discussed the issue with the patient without her
husband present through the translator. They were able to learn that she adamantly refused
the C-section. After some discussion, the translator shared that the patient said she had heard
that the university doctors wanted to practice C-sections and that members of her community
had warned her that nearly everyone who came to the university hospital ended up with a Csection. She said that she wanted more children and that it was not safe to have vaginal births
following a C-section. She also said that sometimes babies died during birth and that if this
was what happened then she would grieve this loss.
 Sarah Shannon. Adapted from a local case.
CASE 2: Mr. Leary - Killing or allowing to die?
Mr. Leary is 76-years-old and had his first stroke three months ago. It was severe but he
was making progress when he suffered a second stroke. After this he was quite depressed
and aphasic with left-side paralysis. Three weeks ago he suffered a third stroke. While it
worsened his physical condition somewhat, this third stroke seemed to improve Mr.
Leary's mood. He is cooperative with care now, even attempting to assist with shaving
each morning. Mr. Leary has no swallow reflex. Consequently, he has a Keofeed tube in
place to administer nutrition and hydration that is tolerated well. His physician wrote that
his prognosis for survival was probably less than a year due to the probability of continued
cerebral events--but he might live as much as three to five years.
Mrs. Leary is overwhelmed. Two nursing homes have been located by the social worker
but she refused each, one was too far from their home (75 minutes drive) and one was
too awful (the social worker concurred). In the three months of hospitalization since Mr.
Leary’s first stroke, he has occasionally had a no code order. However, when his condition
stabilizes he is changed to a partial code. These changes apparently follow discussion
between the physician and Mrs. Leary although this discussion is not recorded in the
chart. The nurses overheard conversations between the doctor and wife regarding the
appropriateness of aggressive care.
On Thursday, a representative from the hospital business office approached Mrs. Leary to
inform her that on Monday Mr. Leary would be decertified by Medicare and that she
would be responsible for hospital charges after that date. On Friday Mrs. Leary called the
physician and asked that the Keofeed be withdrawn, something they had discussed on
other occasions but which Mrs. Leary had previously refused. The physician phoned the
unit and left a verbal order to remove the Keofeed, discontinue feeding, and to not
attempt resuscitation. The nursing staff was very upset and called the physician back to
discuss the order. He stated that, "this is congruent with the patient's stated values prior
to the first stroke. The patient asked me not to over do it." The Keofeed was pulled Friday
afternoon, although the nurses remained very distressed.
On Sunday morning, the patient reached for a glass of water sitting by the bedside for
mouth care (apparently from thirst) and aspirated. By Monday pneumonia was evident.
Over the weekend arrangements have been made to transfer the patient to home to
be cared for by his wife. Mrs. Leary was nearly hysterical. She had not been
participating actively in her husband's care and now realized that she is physically
unable to provide total care including turning, positioning, etc. Mr. Leary was
discharged to home Monday afternoon significantly febrile. He died late Monday
evening.
 Sarah Shannon. Adapted from a personal case.
CASE 3: Joe Jones – Providing futile therapy in the ICU?
Joe had been diagnosed with head and neck cancer 4 years ago. At the time he was told he had
six months to live. Joe had beaten the odds for a while but had been admitted to the hospital
two weeks ago in deteriorating health. A bowel obstruction was assumed to be metastasis of the
original cancer but Joe refused to believe this. After much discussion, the surgeon agreed to do
an exploratory laparoscopy to confirm the diagnosis. This procedure revealed over 100 sites of
studding in the peritoneal cavity. Joe continued to deteriorate over the next 2 weeks but insisted
that he wanted everything done including CPR in the event of an arrest. As his condition
worsened, Joe required constant fluid resuscitation to maintain his blood pressure. As this fluid
leaked into his peritoneum, pressure on his diaphragm compromised his breathing necessitating
intubation and mechanical ventilation. In addition, Joe has needed to be placed on inotropic
pressure support to avoid an arrest. The physicians involved in Joe's care agree that his prognosis
is, at best, 2-3 weeks of life in the ICU.
Joe has no family but many friends. His friends have visited and tell him to "give it up, it's over."
Joe is fully competent and able to communicate by notes. A chaplain and psychiatrist visited Joe
and determined that he does not seem to be motivated by any religious beliefs or untoward fears
about death or dying. He is a watchful patient always monitoring any changes to the ventilator or
drips. Each time the physician asks Joe whether he wants CPR, he indicates emphatically that he
does. The nurses in the unit are upset that they must participate in what feels like futile care.
Also, they are dreading the inevitable code.
 Sarah Shannon. Adapted from a personal case.
CASE 4: Sammy – Too young and too small?
Janelle and James Jones are both attorneys in their 40s. They were joyously awaiting
the birth of their first child – which they expected several months from now. One night,
they rushed to the emergency room with Janelle in hard labor after only a 25-week
gestation. Despite the intervention of the hospital staff, their son Sammy was born
prematurely, weighing just over 1.5 lbs. He required immediate medical attention and
was put on mechanical ventilation in the NICU. He developed necrotizing enterocolitis
and required surgery to remove part of his intestine. Within days of surgery, he had
Grade 4 cerebral bleeding. Yet he hung on. Either Janelle or James was at Sammy’s
NICU bedside nearly 18 hours a day.
From birth, Janelle’s and James’ interactions with the NICU staff were problematic. It
started when a nurse asked Janelle if she had obtained prenatal care. Janelle replied
that the question was racist and that the nurse was clearly uneducated to not be aware
that African Americans of all socioeconomic levels were at risk for premature and lowbirth weight infants. Whenever James visited Sammy in the late evening, he was
frequently stopped by the hospital security and questioned. To make matters worse, a
first year resident told the parents soon after Sammy’s birth that there was little hope
he would survive and that they should prepare themselves for his death – yet Sammy
did not die. The final blow was when Janelle discovered in Sammy's chart that he had
been tested for cocaine and other drugs soon after birth. Janelle and James feared that
hospital was not providing Sammy with the highest quality care available due to staff’s
prejudice that they “caused” his premature birth through poor care or drugs. They also
feared that the physicians were giving up on Sammy sooner than they would have given
up on another child – in particular, a white child.
 Sarah Shannon. Adapted from a personal case.
CASE 5: Heather – Can we ‘give up’ on a kid?
Heather, an engaging 7-year-old, was brought to the ER with a sore throat that had
rapidly worsened and was now threatening her breathing. She was alert and able to shake
her head ‘yes’ and ‘no.’ She was admitted to the pediatric intensive care unit for
treatment of impending septicemia. Triple antibiotic therapy was started immediately but
within hours she required intubation and inotropic medications to support her blood
pressure. Her condition continued to deteriorate over the next three days requiring
increasingly aggressive treatment to support her cardiovascular functioning. The result of
this treatment was that circulation had been comprised to her extremities. Both of her
arms below the elbows and both legs below the knee would need to be amputated,
should she survive. In addition, it was not clear she would survive. She remained
unconscious, septic, and clinically unstable.
On the 10th day of hospitalization, her parents requested that treatment be stopped. They
said that they believed everything that should be done for their daughter had been done
and that “God was calling her home.” They seemed calm and confident in their choice.
The healthcare team was astonished by the parents’ request. No one had approached
them about withdrawing therapy. While some clinicians agreed that the child’s prognosis
was grim and future quality of life would be severely compromised, others felt that
Heather deserved a chance to survive and conquer her disabilities as so many other
pediatric patients demonstrated daily.
 Sarah Shannon. Adapted from a personal case.
CASE 6: Mrs. Pearlman – would we be killing her or abiding by her wishes?
Mrs. Pearlman had suffered a small bowel infarction 7 years prior requiring surgical removal of
her entire small intestine. Subsequently, Mrs. Pearlman had been maintained on total parental
nutrition (TPN) at home with the assistance of her large and supportive family. Mrs. Pearlman's
general health had been declining for several years. While still entirely self care for the activities
of daily living, Mrs. Pearlman had stated often that her quality of life was not adequate because
of frequent bouts of the flu, colds, etc. In addition, the TPN had caused renal damage, which
would necessitate chronic hemodialysis within one year. Mrs. Pearlman had clearly and
repeatedly refused chronic dialysis (recorded in her medical record by her primary physician).
Four days ago Mrs. Pearlman was taken by her family to the emergency room of their local
community hospital with complaints of stomach pain. Within a short period of time her
condition worsened and she was transferred to a tertiary care center to receive a CAT scan of her
abdomen. Upon arrival Mrs. B "crashed" requiring intubation, mechanical ventilation, and
inotropic support. She was transferred to the critical-care unit where she has remained for the
past three days. At this time, Mrs. Pearlman is acutely septic requiring dopamine at 5-8
mcg/kg/min to maintain a systolic blood pressure of 80. She has had a 10 kg fluid gain with a
urine output of less than 30cc per hour. Currently, Mrs. Pearlman's ventilator settings are FiO2 =
80, AC 12, TV 800, PEEP 10. Her arterial blood gases are adequate. She continues to spike
temperatures to 103 degrees Fahrenheit but no source of infection has been found. Antibiotic
therapy has been initiated including Gentamycin IV. Mrs. Pearlman is obtunded with minimal
response to deep pain.
Mrs. Pearlman's family is distraught. While their mother had not signed a Living Will, she had
spoken frequently of not wishing heroic treatment, such as dialysis. Her family stated that they
had promised her they would not allow "heroics."
 Sarah Shannon. Adapted from a personal case.