Clinical Case Study
After suffering an inferior myocardial infarction at an outlying hospital, Mrs. R., 71 years old, was admitted to the critical care unit at a nearby urban medical center for cardiac catheterization. Her only known past medical history was mild hypertension. Although her vital signs were stable on admission, she complained of mild shortness of breath. She was placed on 2 liters oxygen via nasal cannula. A few bibasilar crackles were heard on examination. Within two hours of her arrival, she went into respiratory distress. The ICU attending physician arrived, flash pulmonary edema was diagnosed, and Mrs. R. was sedated and intubated. Central lines were placed. Her heparin was continued, dobutamine (a heart stimulant) begun, and IV push lasix every eight hours was started. Although the patient was sedated, she was responsive to tactile stimuli.
In a living will signed a year earlier, Mrs. R expressed her desire not to be kept alive on a ventilator if she was "in a dying process." The ICU attending physician did not classify her condition "a dying process," and defended the intubation. The original cardiologist came to the unit, surprised at the current situation. He stated that "her heart on echo (echocardiogram) had actually looked pretty good." Her ejection fraction (the amount of blood ejected from the heart with each beat) was estimated to be 40%. (A 65% ejection fraction is considered good.) Her deferred her care to the ICU attending physician.
The following day Mrs. R. was extubated. Indicating that she did not feel well, she told the nurse she was going to die and "that's OK." No conversation took place regarding her living will and no request was made to amend it. Her vital signs were stable for several hours, but she suddenly fatigued and was reintubated.. That night, she spiked a fever of 102 degrees. Cultures were sent and IV antibiotics begun. The dobutamine was increased. All invasive lines were discontinued as possible sources of infection and new ones inserted. During this procedure, Mrs. R. kept shaking her head "no." When the nurse specifically asked Mrs. R. whether she wanted continued life-saving measures, she shook her head "no." The physician maintained Mrs. R.'s status as a "full code", telling the nurse, "I'm not convinced she doesn't understand that this is not the end. This woman is eventually going home." A repeat echocardiogram revealed her ejection fraction had decreased to 25%.
Each day Mrs. R.'s pastor repeatedly told the nurses and physicians that Mrs. R. had never wanted to be "kept alive on a ventilator." The cardiologist again deferred to the ICU attending without offering his opinion of Mrs. R's heart failure.
Two days later, with her fever gone, Mrs. R. was weaned off the dobutamine and ultimately extubated. She was weak and showed little interest in communicating with staff. She went into ventricular fibrillation (essentially cardiac arrest) later in the day and was coded and reintubated. Lidocaine was started for the arrhythmia, dobutamine was restarted, and then dopamine was hung when her blood pressure began to fall. Urine output suddenly decreased, dopamine was increased, and her creatinine jumped from 1.4 to 2.3. Mrs. R's close friend told the nurses that Mrs. R. "would never have wanted to be put kept alive like this." This information was communicated to the ICU attending.
On day five, Mrs. R's pastor arrived and accused the staff of "playing doctor" asking, "how long is this going to go on?" The physicians assured him that eventually she would come off the ventilator and go home. The dopamine was gradually weaned off as her urine output began to increase slightly. The dobutamine and lidocaine remained.
On Day 7, Mrs. R. was extubated again. Her affect was flat and she slept most of the time. The dobutamine was gradually weaned off. When asked whether she would want to be intubated again if the need arose, her answers were unclear and her level of consciousness deteriorated. She began showing signs of respiratory failure before an CT scan of her head could be completed. Mrs. R's nurse called the ICU physician to report that a Code Blue was probably imminent and asked whether he really wanted Mrs. R. to be reintubated. The physician ordered the nurse to begin a Code if necessary. A code was eventually begun. Mrs. R.'s friend told the nurses in the room that Mrs. R. had said to her earlier in the day that she was "going to die and go to my house and get my papers." During intubation, Mrs. R went into ventricular tachycardia. Advanced Cardiac Life Support protocols were, as usual, followed. She went back to a normal sinus rhythm, was switched to IV Amiodarone (for cardiac arrhythmias) and the dobutamine was restarted. She was intubated for what would be the final time.
Meanwhile, the patient's hemoglobin and hematocrit had dropped to 7.8 and 25% respectively. An gastric endoscopy was ordered and completed. An upper gastro-intestinal bleed was diagnosed and the patient received two units of blood without her express consent. The ICU physician ordered the blood as a "medical necessity." That night Mrs. R. went into sustained ventricular tachycardia (a rapid heart rate), then ventricular fibrillation. ACLS protocols were followed for 45 minutes, but a cardiac rhythm was never re-established, the code was stopped and Mrs. R. was pronounced dead. The ventilator was turned off.
Questions for Discussion and Further Study
1. Given the initial prognosis of this patient, would the nurse(s) taking care of this patient have good reason to experience "moral distress" about the continued care she received by the ICU physician?
2. Describe all the competing interests in this case and the ethical stance from which each party is operating (autonomy, etc.).
3. Were the patient's wishes ambiguous or were they clear enough for the nurses to exercise their "moral autonomy" themselves and advocate more aggressively for the patient? What could the nurses have done to bring more clarity to this situation?
4. Was there a point(s) during this case when the nurses could have refused to implement the orders of the physician? Should they have?
5. Were the patient's wishes and her quality of life respected during this hospitalization? If no, what should have been handled differently?