Question

Case Study #1:

A 75-year-old healthy male was working on the roof of his house when he slipped and fell 10 ft. to the ground. He was knocked unconscious. When the paramedics arrived, he was awake but confused. His vital signs were stable (e.g., Glasgow Coma Scale [GCS] score of 14). He was immobilized with a C-collar and backboard and taken to the ED. Shortly after arrival in the ED he became more confused, then sleepy. His GCS score decreased from 14 to 10. The attending emergency physician was concerned that perhaps the patient had a significant head injury and was in the process of arranging for a CT scan when the patient’s wife arrived. The patient’s condition continued to deteriorate, to a GCS score of 8. The emergency physician prepared to intubate him, but when she discussed this with the patient’s wife, the wife became upset and stated that her husband had a “living will,” which specifies that, if he became critically ill, he would not want any resuscitative interventions, including intubation.

Questions:

• What are some of the ethical issues in this case?
• Was the patient adequately informed when they declared their wishes?
• Did they put these wishes into a particular context?
• That is, were they intended for reversible, or irreversible illness?
• Is the patient’s wife required to make a decision in the best interests of the patient, who decides what is ‘best’?

Answer 1

A living will is a document that indicates a patient’s wishes regarding their health care and how they want to be treated should they become seriously ill and unable to make or communicate a decision of their choice. However there is some evidence that it is much more difficult to anticipate a person’s state of mind when dying than had been thought, and equally as hard, if not impossible should one be in a coma. In order to understand both sides of the issue we must take a look at both sides

A living will is considered to be only valid in situations where the patient a terminal illness, which is described as a medical complication that is incurable or irreversible without the administration of life-sustaining devices and procedures.

Advantages of the living will are:

They respect the patient’s human rights, and their right to reject medical treatment

Creating them encourages debates regarding end of life decisions

The doctors are more likely to give appropriate treatment after knowing the patient’s wishes

Helps in difficult decision making by the medical professionals

The patient’s family and friends do not have to make the difficult decisions

Disadvantages of the living will are:

Writing them can be very depressing

It can be very difficult for a healthy person the adequately imagine or decide what they want in the situations where a living will would take effect

Translating the words of a living will into medical action could be difficul

Patients may change their minds and not remember to change their living wills

If the living will is not available at the time it is needed it is of no use to the patient, doctors or family

It is believed that Kerrie Woolthorton is the first person to use a successful suicide attempt. The 26 year old wrote her will, then three days after took poison and called for an ambulance. The will stated that no attempts to be made to prolong her life, that she was to be made as comfortable as possible and not to be left to die alone.

If doctors had chosen to keep Woolthorton alive, they may have encountered some legal action. If doctors had gone against Woothorton’s wishes and interfered it would have been interpreted as an assault. Nevertheless might there be a moral case for ignoring a living will under such circumstances?

One immediate concern is whether or not the patient is sufficiently competent to make a decision this important. One must be careful not to judge the competence of the individual by the content of the decision. In most cases individuals are the best judge as to whether their life is worth living. If a person to chooses to end their life in circumstances in which we would choose to live our lives, it is not sufficient to judge them as incompetent. Thinking of the decision foolishness and imprudent, still does not make it an incompetent decision. In this case the coroner was clear that Woolhorton had the capacity to consent and had full knowledge of the consequences of her actions.

The other side of the argument put for by the “ProLife Alliance,” is the

“so- called thank you theory”. Meaning that in some cases people saved under similar circumstances are glad to be rescued, a policy of general interference with the person’s stated wishes is justified