NSRG 101 Cases Assignment

Medical Ethic Cases

1. CG was born a mitochondrial DNA depletion syndrome (MDDS), a rare genetic disorder that causes progressive brain damage and muscle failure. MDDS has no treatment and usually causes death in infancy. When he was 11 months old, CG was admitted to the hospital in the UK for failure to thrive and difficulty breathing. He was placed on a ventilator and began having persistent seizures which caused irreversible brain damage. A neurologist in the US was contacted who was working on an experimental nucleoside treatment for MDDS was contacted about using this potential treatment for CG, but the neurologist said that the treatment was unlikely to help if there was already irreversible brain damage, although there was a very slight possibility that it may help. After CG experienced worsening seizures for 2 weeks, CG’s physicians determinedthat the experimental treatment would be futile and would not be in CG’s interests to undergo nucleoside therapy. They began discussing with the parents the ending of life support and provision of palliative care. The parents refused to withdraw life support and indicated that they wanted to take him to the US for the experimental treatment.  Some key questions to consider for this dilemma are:
   • Should experimental treatments be conducted on a patient if they are most likely going to be futile and could cause pain?
   • Who should determine what treatments the child receives?
   • What is a parent’s role in decision-making for children and when, if at all, should parents requests for medical treatment be overruled?
   • Is it in CG’s best interest to continue to be ventilated?
2. TS was a woman who went into cardiac arrest at the age of 26. She was successfully resuscitated but had massive brain damage due to hypoxia to the brain and was declared to be in apersistent vegetative state. For the next five years, physicians attempted multiple different therapies hoping to return her to a state of awareness without success. After 8 years, her husband petitioned the court to remove her feeding tube, saying that his wife would not want to be kept alive on a machine, but was opposed by her parents who said that she was a devout Christian who did not believe in euthanasia by withdrawing nutrition and hydration. She did not have an advanced directive. In court, three of five physicians testified that TS was in a persistent vegetative state, and two physicians said she was in a minimally conscious state. Her parents claimed that she occasionally did respond to them and that withdrawal of a feeding tube and hydration would cause her suffering.  Some key questions to consider for this dilemma are:
   • Was she in a vegetative state or minimally conscious state?
   • What if any hope of recover did she have?
   • What would TS want regarding life-sustaining treatments?
   • Is the profession of fluid and nutrition humane comfort care or a medical intervention that can be refused, withheld or withdrawn?
3. DC was a 25 year old man who sustained debilitating injuries from a propane gas explosion that led to severe burns on all parts of his body except his feet, the complete loss of vision, profound hearing loss, and required amputation of both his hands. His daily burn treatments were excruciatingly painful, which he would have to endure for at least two years, and he requested healthcare providers to help him to die. Some key questions to consider for this dilemma are:
   • Should a person be free to determine how much suffering is too much?
   • Is it humane to help a person die with dignity or is it a violation of human dignity to help end a life?
   • Would it make a difference if this patient was 85 years or had a terminal illness, such as Stage 4 cancer?
4. MM was a healthy 33 year old woman who was 18 weeks pregnant when she suffered a pulmonary embolism, and was put on a ventilator. A few days later, she was declared brain dead. Her husband petitioned the hospital to remove all life-sustaining measures, as MM had previously verbally told him that in case of brain death, she would not want to be kept alive artificially. The hospital refused to remove treatment, citing a law that required lifesaving measures be maintained if the patient was pregnant even if there was written documentation that this was against the wishes of the patient. The parents of MM said that while they agreed that their daughter would not want to be kept alive artificially, that they believed she would want to be kept alive until the fetus could be born. Some key questions to consider for this dilemma are:
   • Should MM be kept alive so that the fetus can have a chance at life? If so, how long should she be kept alive for—until viability (~24 weeks) or full term (~40 weeks)?
   • What if the husband had initially said that he wanted her to be kept alive until the fetus was full term but then learned that the fetus had sustained some injury due to oxygen deprivation and would likely have some brain damage—would this make a difference?
   • Should the condition of pregnancy change interpretation of a patient’s wishes expressed prior to pregnancy?
5. CC is a 15 year old teenager who has had HIV infection since birth due to perinatal transmission. The HIV infection has been well controlled her entire life. Her parents inform the nurse and provider that CC does not know that she is HIV positive, andhave no plans to disclose her HIV status “yet.” They think she is too young and is not ready to know. CC has been told by her parents that she has a mild blood disorder, which is why she takes medication on a regular basis. She has begun skipping doses occasionally though because she doesn’t like the medications. The nurse and provider urge the parents to disclose HIV status, especially given CC’s age and are distressed that she doesn’t know and consider breaking confidentiality. Some key questions include:
   • Does CC has a right to know her diagnosis?
   • Do the parents have a right not to disclose the diagnosis to the daughter?
   • What if the nurse and provider knew that CC was sexually active?
   • Should the nurse ever tell the daughter if the parents do not want them to?
6. EL is a 36 year old pregnant woman who presents to the ED in preterm labor. She is 24 weeks 4 days and recently got genetic testing back that confirmed Down Syndrome in the fetus. There is also a high risk for brain damage, neurodevelopmental impairment, eye problems, and chronic lung disease associated with prematurity. Survival rate in a 24-25 week preterm infant is 60-80%. The parents ask the provider not to initiate resuscitation at delivery because they “don’t want a baby with Downs”, knowing that without resuscitation, the infant will die given lung immaturity. Some key questions to consider in this dilemma:
   • Should parental autonomy be respected or should the providers advocate for the infant?
   • Who gets to determine whether to omit resuscitation for an extremely preterm infant?
   • What if the baby didn’t have Down syndrome but parents still were requesting no resuscitation—would that change what you think the provider should do?
   • What if the baby was 22 weeks or 28 weeks?
7. JY is 3 year old boy who was involved in a motor vehicle accident and sustained serious injuries. Although his prognosis is optimistic, he experienced massive blood loss and is in critical need of blood transfusions. Without the blood transfusion, it is unlikely that the child will survive. Although they are incredibly devastated, his parents will not consent for administration of blood transfusions due to strong religious convictions that prohibit them from accepting blood. Some key questions to consider for this dilemma are:
   • What is a parent’s role in decision-making for children and when, if at all, should parents be overruled?
   • What is the duty of the healthcare provider in providing culturally and religious competent care?
   • Would it matter if the child was a 15 year old who also stated that he didn’t want to receive the blood?

Ethical Dilemma In-Class Assignment

Ethical case: