Sunday, October 09, 2005

Your Truth: Confusion and Code Status

Before I provide you with my next scenario for your ethical debate, I want to provide a bit of a disclaimer. The scenarios I have been providing are not entirely like those that might come up in hospital ethics committees.

For ethics committees who follow Thomasma's ethical workup, the questions asked during an ethical dilemma are:

1. What are the facts of the case?
2. What are the values at risk in the case?
3. What are the main conflicts between values, professional norms, and ethical axioms, rules, and principles?
4. What are the possible courses of action, and which values do the possible courses protect or infringe?
5. Having addressed all prior questions, which course of action do we think is most ethical?

The first question, what are the facts of the case, can sometimes be the hardest. The facts are not always as clear as I've been presenting them to you in these scenarios.

In this next case, I will not unravel all of the facts. The facts themselves will be harder to interpret. Do you see how these differing facts might affect your decision?

Mr. Garcia is a 39 year-old male admitted to the hospital with uncontrolled pain from metastatic colon cancer. He is very confused; he doesn't know the date nor where he is nor the time of day. He asks you repeatedly if he is still going to be able to "play in the game." He later states, "But I am not one of the players; I'm a coach." He appears in excellent health from outward appearances despite his highly advanced cancer. His skin coloring looks healthy. His vital signs are stable and he has excellent urine output, all signs suggesting his body is holding up in spite of his progressing disease.

Mr. Garcia lives with his 18 year-old daughter whom brought him to the hospital; however, she has not been back to the hospital in the two days since his admission. He tells you repeatedly that he wants to go home to talk to her.

During Mr. Garcia's previous admission, he stated that he wished to be a DNR/DNI (do not resuscitate, do not intubate). However, due to his altered mental status, the doctors have not determined a code status yet, hoping his mind will clear before the issue of code status becomes pressing. This means that for now, Mr. Garcia is a full code (meaning all efforts will be made to keep him alive or bring him back to life if he stops breathing or his heart stops beating).

What are some potential ethical issues that might present in this case?

Although I've tried to minimize interpretting data to illustrate the difficulty in determining facts, I will provide a little more information for those of you with less of a medical background. The type of confusion that Mr. Garcia is presenting may possibly be (but may not be) attributed to what is referred to as terminal delirium (confusion that occurs in more than 25% of patients with advanced cancer in the last month of their life). However, this confusion could also have been induced by the opioids that have been used to manage Mr. Garcia's pain. Terminal delirium is not likely to respond to pharmacological interventions, whereas opioid-induced delirium may.

Okay, I'll stop there. What are your thoughts?

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