Case Studies

End of Life/Advance Care Planning Case

Mr. A is a 94-year-old male with a history of multiple medical issues, including DM II, HTN, CAD s/p stenting, Parkinson's disease, and moderate Alzheimer's dementia who is a current resident at a long-term care facility. He has lived at this facility for approximately 3 years and has recently experienced a significant decline. When he first arrived at the facility, he had a BIMS score of 12/15 and was fairly interactive. Speech pathology administered the Montreal Cognitive Assessment (MoCA) at that time as well and noted a score of 21/30. You have cared for him throughout his long-term care stay and appreciate the decline as well. When you first admitted Mr. A, you performed a thorough capacity evaluation and had a productive advance directive discussion. At that time, he was deemed to have capacity and an advance directive was completed as Do Not Resuscitate and Do Not Intubate. He also did not want a feeding tube after discussions regarding artificial nutrition and hydration. He did name a healthcare agent (HCA) at that time who was a friend that he had known for many years.

Now, Mr. A does not have the capacity to make his own healthcare decisions, given his decline. He has lost about 30 pounds in the last 6 months, is cachectic and staff also noticed him pocketing his food much more often. He has had two episodes of aspiration pneumonia during this time as well. Thus, he clearly is in the advanced stage of his dementia, such that he would be considered terminally ill. Given this change in condition, you review his advance directives with his HCA, and she is understanding of his previous wishes. However, she brings up a conversation she had with him many years ago, when he mentioned he would like to try a feeding tube and explore that. What are the appropriate next steps?

Ethical principles that could assist in appropriate ethical decision-making

  1. Patient autonomy vs. nonmaleficence
  2. Informed consent
  3. Fluctuating nature of capacity determination
  4. Beneficence of a feeding tube in this case
  5. Palliative care    

 

Sexual Expression Case

Mrs. S is an 86-year-old female who currently resides in an assisted living facility. She has a known history of moderate vascular dementia with a previous CVA about a year ago but has improved somewhat since that time. Her last MOCA was done about 6 months prior and was found to be an 18/30. She is often found walking the hallways and is fairly functional. Three months ago, her husband of 40 years died, and she was informed by her children. She attended the funeral and seemed more withdrawn/depressed over the following weeks. Recently, staff reports to you that they have observed Mrs. S in the room of Mr. J, a male resident at the assisted living facility, touching his shoulder and hugging him. Mr. J has a diagnosis of vascular dementia as well and is in the moderate severity range. His last MOCA was about 3 months ago and scored 16/30. Staff initially felt that it was just friendship, but then they noticed them in bed together under the covers, and Mrs. S had her brief below her knees. The staff stated they did not seem upset or anxious and appeared comfortable at the time; however, the staff felt it was safe to separate them for the time being until further discussion with facility administration and the medical staff. During the time staff has noticed this friendship beginning between the two residents, they note that their mood has improved and they seem happier than in the recent past. What ethical principles can help guide you in this situation?


Ethical topics and principles that can be applied in this case

  1. Informed consent for sexual acts and relationships
  2. Assessment of capacity
  3. Involvement of the healthcare agents and family
  4. Resident rights to safety and privacy
  5. Staff involvement and their own ethical beliefs regarding the situation


Justice and Ethical Case Involving Resident Transfers

Mr. B is a 62-year-old male with a history of multiple severe medical issues, including advanced stage ALS, chronic respiratory failure on bipap and supplemental oxygen, dysphagia, CAD, and CKD, who is a current resident at the long-term care facility where you serve as medical director. Over the last 6 months, Mr. B has had recurrent episodes of aspiration pneumonia severe enough to lead to 3 hospitalizations.  He has also had worsening daytime fatigue. The medical team feels that his condition is declining and that he is getting close to requiring further aggressive interventions such as intubation, a tracheostomy tube, and/or a feeding tube. Mr. B has been very clear through his advance directives that he would want to live as long as possible and wishes to pursue all aggressive interventions. Family is aware of this wish as well and support him.

A week ago, he unfortunately had another acute event requiring hospitalization and is being treated for pneumonia. He has stabilized relatively close to his previous baseline and the hospital is requesting he be discharged back to the facility for ongoing care. The medical team and facility are uncomfortable with this and are therefore declining his readmission to the facility until there is a more long-term treatment plan in place. The physician caring for him at the hospital calls you (as medical director) and is upset about  this, given how busy the hospital is. He feels that a feeding tube can be done as an outpatient. Mr. B is also worried about returning to the facility without a clearer plan. What are the ethical principles and/or ways to help resolve this situation?

Ethical Principles and topics that can help in this situation

  1. Legal and regulatory implications
  2. Principle of Justice for both the hospital and the facility
  3. Role of an ethics committee in this case?
  4. Nonmaleficence and the harm repeated hospitalizations can cause without a true intervention
  5. Autonomy
  6. Impact of external factors such as relationship with the hospital and the local health system


Ethics of Moral Distress in Facility Staff

You are the current medical director of a relatively large long-term care facility that has a very complex patient population, including long-term ventilator patients, neurobehavior patients, a locked dementia unit, and a large short-term rehab population. A staff member on the neurobehavioral unit has RSV and was working on multiple units in the building that day, thus creating a large exposure risk to the residents. This was reviewed with the administration of the facility and given the complex nature of the residents that they care for, it was decided to shut down all resident activities and communal dining and limit resident-to-resident interactions. After this decision, many staff in the building have reported feeling that this is unfair, especially given that it is the holiday season. Some nursing staff feel that this may actually harm residents, who will not get the appropriate social interactions they deserve. The administration of the facility would like you and the infection control nurse to meet with the staff to discuss their concerns.

You meet with some of the nursing staff and they seem very frustrated. They know that they did this with COVID but why do they need to do this for every virus? They want to know how these decisions are made and why their concerns are not being heard.

What are the ethical issues and topics that can be addressed

  1. Exploring the moral values and concerns with the staff
  2. What courses of action are there if staff continue to feel morally distressed by this case?
  3. Ethical Principle of Justice and its role here
  4. Nonmaleficence
  5. Legal and regulatory implications of this decision on the facility at large if a significant outbreak with resident deaths occurs
  6. Ethical review of the facility at large and how to improve the decision-making process throughout all staff levels