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Case Studies:

Barney Says No

Determining the Appropriate Surrogate and the Goals of Care

Almeda was an eighty-four-year-old woman who lived a retiring life with no family and few friends. She suffered a disabling stroke three years ago and has been confined to bed in a nursing home.

Almeda has lost decisional capacity and left no advance directives. Barney, her long time friend, has been her unofficial substitute decision maker. Almeda has developed a stage IV sacral decubitus, now colonized with multiple resistant staphylococcus areus and pneumonia with heart failure. She is now in the intensive care unit.

For two weeks, Alameda has been on the ventilator and fed with a gastric feeding tube. During this time she as been treated with high dose cardiovascular drugs and Vancomycin antibiotic. There has been no progress in the heart failure or pneumonia. Although stoic, Almeda shows clear signs of pain when moved about for care.

The nurses and attending physician have approached Barney on numerous occasions to raise the question about stopping aggressive curative treatment and moving toward palliative care.

Barney has always insisted that he sees more potential in Almeda’s condition. When asked what the right goal for Almeda ought to be, he answered, “It would be good if she could sit up and watch a little television.”

Almeda’s renal function has now become seriously impaired with a serum creatinine rising to levels requiring renal dialysis. With the prospect of dialysis, the nursing staff asked for a meeting with the attending physician and Barney to discuss treatment redirection from curative to palliative care.

Questions for discussion

Use the following questions as guides in discussing the ethical implications of the preceding case.

• Does it make a difference which stakeholder raises the question about treatment redirection? What would have happened if Barney had raised objection to the course of treatment? The nurses, doctors, or Almeda herself?

• Does the absence of advance directives complicate or simplify the treatment redirection process?

• Is Barney an appropriate substitute/surrogate decision maker to consent to treatment redirection to palliative care?

• Should some “official” or “legal” action be taken in order to proceed with a treatment redirection process?

• What would Almeda prefer if she were able to contribute to the discussion?

• Is Barney’s statement of a goal for Almeda adequate to justify continuing aggressive curative treatment?

• Is there evidence from the case text that the attending physician has been active enough in trying to inform and persuade Barney to consent to treatment redirection?

• What should have been the point of view of the nursing staff if Almeda was slowly getting better? What if she were neither improving nor getting worse?

• What is it about the prospect of renal dialysis that stimulates the raising of the treatment-redirection process? Why not when the gastric tube was inserted? Or when the ventilator was started?

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