A Lady with Few Directives

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Robert D. Orr, MD, CM; Ferdinand D. Yates, Jr, MD, MA (Bioethics)

Editor’s Note:[1]

This column presents a problematic case that poses a medical-ethical dilemma for patients, families, and healthcare professionals. As it is based on a real case, some details have been omitted in the effort to maintain patient confidentiality. In this case, the physician has difficulty in identifying the patient’s medical preferences.

QUESTION: How should we make decisions about resuscitation status for this confused woman with no designated surrogate?

STORY:

Nellie is a 97-year-old woman who was living alone in her own home until she was admitted to the hospital four days ago with weakness, decreased mobility, and confusion. She was found to have pneumonia, sepsis, renal insufficiency, and dry gangrene of one toe. She has responded surprisingly well to treatment, but remains frail, somewhat confused, and is at risk of further complications. Dr. Roberts, who has not previously known the patient, has attempted to have conversations with Nellie about her wishes regarding resuscitation, intubation, and other end-of-life care, but she has given inconsistent responses. He believes that CPR with chest compressions is unlikely to work if Nellie’s heart should stop because of her very frail ribs—however, he is not absolutely certain.

The patient, in the past, has generally avoided medical care. Eight years ago, she was hospitalized for a few days with dehydration and then was transferred to a nursing home. Her nurse says that Nellie vividly remembers the nursing home stay and says that it was terrible.

Nellie was an elementary school teacher, retiring about 30 years ago. She has been widowed for many years, has no children, and has no living relatives. She has no guardian and no written advance directive. She lives in her own home and mostly takes care of herself, but she has daily help with cooking and cleaning from a woman—named Bernadette—who has known her only in this capacity, and only for about 2 years. She has an attorney whom she has known for 20 years who is in charge of her financial affairs. He is reportedly not available today, but a progress note written by Dr. Roberts indicates that the attorney says he believes the patient would not want “heroic measures.”

I spoke with the patient. She was chipper and reasonably clear in her responses, but occasionally incomprehensible. I introduced myself as “Dr. Orr from the Ethics Committee.” She seemed to have some level of understanding in that she said with a smile, “Then you better do the right thing,” but she repeatedly called me “Father.” She says she was an active Roman Catholic all of her life but has been unable to go to church for many years. When I asked her if she would want to go to the ICU and have machines or tubes if she should worsen, she said “Well I guess so—if it would help.” I then suggested that if some treatments were not working, it might be appropriate to stop them, and she also agreed. She said she had no close friends, and when I asked if we should talk with Bernadette or her attorney if we had questions about treatment, she seemed uncertain.

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