Dr. Goldstein’s case
Q1. If Ed is not placed on a ventilator, what will happen to him?
If Ed was not placed on ventilator, he would certainly die within few days.
Q2. Was it ethical and appropriate for Dr. Goldstein to call Bert? Was Ed no longer able to take care of himself? Who makes that judgment?
Yes, it was ethical and appropriate to call the patient’s family member, Bert. Ed, because of his poor health, his hearing problem, and primarily, he being mentally retarded, he did not seem to be in a position to even understand what is happening to him and certainly would not be able to think about the best treatments offered to him. In such a scenario, it is best to consult the family member. Besides, Ed had filled out a Durable Power of Attorney, in which he stated he wanted his younger brother Bert to make decisions regarding to his treatment for him, in case he was no longer able to do so for himself.
Q3. Should Dr. Goldstein tell Eric anything? If so, what?
Ideally, Dr. Goldtein should ask for Eric’s identity to be sure that he is a relative of the patient. Though the patient had made a note his younger brother be consulted with respect to his health decisions, the younger brother Bert did not seem to give any clear guidance to Dr. Goldstein on his brother’s treatment. Therefore, it is wise on Dr. Goldtein’s part to talk about the patient’s health to his nephew Eric.
Q4. If Dr. Goldstein tells Eric about Ed's medical situation, what should Eric do? Can Eric authorize Dr. Goldstein to use the ventilator?
The objective of a doctor profession is to save the patient’s life. Considering this, Dr. Goldstein should talk about Ed’s heath to Eric. Eric did show promptness when he learnt about his uncle’s health. To save his life or to add few more days to his life, Eric should give his consent to the treatment option that Dr. Goldstein suggests. Eric being a family member can authorize Dr. Goldstein to use the ventilator.
Q5. What should Bert tell Dr. Goldstein to do?
Bert is also an old man, shy, and does not like to make decisions. In that case, he should direct Dr. Goldstein to Eric, who is young, is concerned about his uncle’s health and seems to have a capacity to make decisions regarding his uncle’s treatment.
Q6. Would your opinion change if Ed simply has a case of mild pneumonia and, if appropriately treated, could resume normal life?
Yes.
Q7. Would your opinion change if Ed is known to have a defective gag reflex and will probably need the ventilator and feeding tubes for the rest of his life?
In that case, it is best to involve the family member (Eric) and explain the situation to him appropriately and take his consent. Taking a decision of putting the patient on ventilator and feeding tubes is also a significant cost which the family should agree to spend.
Q8. If Ed has clearly indicated in his Advance Directive that he does not want to be put on a ventilator, why does Dr. Goldstein want to put Ed on a ventilator? Is that ethical?
As we saw earlier, a Doctor’s objective should be to save a patient’s life and give the best possible treatment to his patient, it would be ethical on Dr. Goldstein’s part to want to put the patient on ventilator even if he has clearly indicated that he does not want to. Since Ed is old and has some mental retardation issue, he might not have been in the best of his mental health to take appropriate decision on his health.
Q9. Since Ed said he does not want to be put on a ventilator, would it be ethical for Bert to authorize a ventilator anyhow? Under what circumstances?
Yes. The above answer applies to this question too. A ventilator could prolong the life of the patient. Since Ed did not have a sound mental health, it is ethical for Bert to authorize the treating doctor to put his brother on ventilator.
Q10. Would removing a ventilator and feeding tube the next day be wrong?
Certainly. It would prove to be dangerous to the patient.
Q11. Bert has just been told that he needs surgery to treat blockages in his renal arteries. If Bert is unable to make decisions about Ed's health care, who would?
Eric should ideally take decisions.
Q12. If Ed had indicated in his Advance Directive that he wanted everything possible to be done to keep him alive, could Bert decide to refuse placing Ed on a ventilator?
No. The treating doctors should do what is best for their patient (to save patient’s life).
Q13. Imagine that Eric's mother thinks that Ed should be kept alive no matter what. Should that make a difference to Bert? To Dr. Goldstein?
It should not make a difference to Bert. Dr. Goldstein should be happy that with family’s consent he is able to add few more days to his patient’s life.
Q14. Dr. Goldstein is trying to communicate. How did he do?
First Dr. Goldstein tried to communicate to Ed. Since Ed had a hearing problem, Dr. Goldstein had to shout on the top of his voice so that Ed could hear him clearly. When Ed failed to understand once, Dr. Goldstein again tried to speak in a loud voice, but Ed was not clear this time too. As a responsible doctor, Dr. Goldstein called his younger brother Bert and explained about his health. On Eric’s arrival to the hospital, Dr. Goldstein promptly explained the case to Eric.
Situation 1:
Nursing principle: Fidelity
Situation 2:
Nursing principle: Beneficence
Situation 3:
Nursing principle: Beneficence
Situation 4:
Nursing principle: Beneficence; Principle of autonomy cannot be applied
Situation 5:
Nursing principle: Fidelity
Situation 6:
Nursing principle: Autonomy
Consensus
All cases described under all six situations are more or less similar. A mentally weak patient normally has a chance of getting into a nervous breakdown upon learning of his illness. The family members are the ones who know the patient’s mental status well; and therefore would be hesitant to inform the patient that he/ she has been affected with such a deadly disease. In such a scenario, it is best to inform the patient only that much that would enable him to follow his doctor’s instructions carefully and correctly with respect to treatment and follow ups. It is not necessary to inform the patient and give every fact/ information about the disease. It is required that family members and his treating physician and other health care professionals involved in the patient’s treatment keep certain information in confidence while supporting the patient all the time so that he doesn’t refuse to treatment and is willing to take care of himself/herself to recover from the illness.
