1 CASES FINDING THE KEY

2 MR. THOMAS I [POLICY] Mr. Thomas is a 75 year-old patient who is suffering from end- stage COPD (emphysema). He has made frequent visits to the hospital in the past two years but after 7-10 days on the ventilator he has recovered enough to return home where he is tethered to an oxygen tank and can leave his home only with great difficulty. WHAT IS THE FIRST THING THAT SHOULD BE DISCUSSED WITH MR. THOMAS TO PREPARE HIM FOR HIS FUTURE? SHOULD THE PHYSICIAN BE TALKING WITH MR. THOMAS ABOUT FUTILE CARE IN THE FUTURE?

3 MR. THOMAS II He has recently been diagnosed with lung cancer and the prognosis is that he has less than six months to live. He has elected to undergo chemotherapy for his cancer against the advice of his physician who has said that the chemotherapy will not really retard the growth of the cancer significantly and will only make him more miserable because of the side-effects of the therapy. SHOULD THE PHYSICIAN BE BLUNT ABOUT THE FUTILITY OF THE CHEMOTHERAPY? HOW SHOULD MR. THOMAS’ VALUE LIFE BE EXPLORED TO DETERMINE WHY HE WANTS TO GO AGAINST HIS DOCTOR’S ADVICE? SHOULD THE PHYSICAN TAKE INTO ACCOUNT PERSONALLY-DETERMINED FUTILITY TO GIVE MR. THOMAS THE BEST CARE?

4 MR. THOMAS III As a result of the combination of the two diseases, Mr. Thomas' lung function has deteriorated rapidly and he has been admitted to the hospital where the pulmonologist says that he will never be weaned from the ventilator. His oncologist, his pulmonologist, his internist, and his intensivist all agree that no therapy will improve his condition and that he is effectively dying although he may not die soon. It may be a matter of weeks or a month or so at the most. He tells his physicians that he wants everything done to prolong his life and his family concurs with his decision. He said “I’ve paid taxes all my life and I’m gonna get my money’s worth out of Medicare.” IS VENTILATOR SUPPORT FUTILE? SHOULD THE PHYSICIANS REFUSE ANY ADDITIONAL INTERVENTIONS? IS MR. THOMAS’ ATTITUDE ENOUGH TO JUSTIFY FUTILE CARE?

5 MR. THOMAS IV He has an advance directive, which reinforces his wishes and his daughter who is his healthcare proxy agrees to follow his wishes if he loses decisional capacity. The physicians reluctantly agree to follow Mr. Thomas' wishes in part and they keep him on the ventilator and continue the chemotherapy. However, they agree among themselves that they will not offer him CPR nor will they perform it if he gets into cardiac difficulty. Nor will they use antibiotics if he develops an infection. Both orders were written in the chart without the knowledge of either the patient or the family. CAN A PATIENT DEMAND FUTILE CARE IN AN ADVANCE DIRECTIVE? CAN THE PHYSICIAN MAKE A UNILATERAL DECISION NOT TO PROVIDE FURTHER CARE? COULD THE PHYSICIANS KEEP HIM ON THE VENTILATOR AND STOP THE CHEMOTHERAPY? HOW COULD A HOSPITAL POLICY HELP IN THIS CASE?