1. Current Legal and Ethical Controversies in American Health Care
Medical Planning and Care at a Time of Advanced, Irreversible Illness

2. Instructors Marshall B. Kapp, J.D., M.P.H. Kenneth Brummel-Smith, M.D.
Charlotte Edwards Maguire Professor, Department of Geriatrics

3. Case 1 Mrs. C, 75-year-old widow Severe emphysema
Found unresponsive at home
EMS performed endotracheal intubation and resuscitated her.
Admitted to hospital and treated for respiratory failure and pneumonia, now lucid and able to communicate

4. But, cannot be weaned from the respirator
After several weeks, Mrs. C wants the respirator removed.
No advance directive or prior discussions ??

5. Case 2 Mr. V, 86-year-old man Advanced dementia Sectarian nursing home
At a certain point, stopped eating and put on NG tube
Bedridden, incontinent, lies in nearly fetal position, in apparent distress, pulling at feeding tubes

6. Wrist restraints
Several comorbidities

7. Only relative is cousin, who wants feeding tube discontinued.
Years earlier, Mr. V said, “If I ever become senile like my neighbor, please shoot me.”
NH refuses, citing religious beliefs
Physician refuses to “starve” Mr. V to death

8. Case 2 A
Same as Case 2, except Mr. V is a 26-year-old man with severe traumatic brain injury suffered in a motorcycle accident?

9. Case 3 Ms. M., 88-year-old widow NH resident for 2 years
Moderate dementia, confused but some interaction with other residents and in generally good physical health

10. Only relative is a son to whom she gave durable power of attorney (DPOA) when Ms. M entered the NH.
NH notified son that Ms. M developed a bad tooth abscess and requested consent to have her treated by a dentist.

11. Son refused. “Mom has lived a good, long life
Son refused. “Mom has lived a good, long life. At this point, she shouldn’t be burdened with a bunch of people poking and prodding her.”

12. Case 4 Ms. L, 85-year-old widow with dementia
Admitted to NH from hospital 2 years ago. Hospitalized for hip fracture incurred in auto accident while still driving. Prior, lived in apt. with her sister.
Chronic lymphocytic leukemia and hypertension now

13. Did OK in NH, but progressively more severe dementia.
Paces, talks to herself.
Periodic blood transfusions to control leukemia, does not understand and sometimes resists. Necessary to sedate and restrain her during transfusion.

14. 2 years before car accident, Ms. L executed advance directives:
DPOA naming sister as agent
Living will—”…I do not want medical interventions that prolong my life if I have an incurable or irreversible medical problem that is not terminal, but which inflicts upon me severe or progressive physical and/or mental deterioration and loss of ability to function normally.”