PHI 324 – Case Study The Case of Mrs. M Mrs. M was a 54 year-old woman who was transferred to a tertiary care hospital's critical care unit from a community hospital. She had been diagnosed with an acute anterior wall myocardial infarction (heart attack). Secondary diagnoses were acute pancreatitis, disseminated intravascular coagulation, acute respiratory failure, and lactic acidosis. She was placed on a ventilator. Due to medication and her serious medical problems, she was only periodically alert, but responsive when directly addressed. There were no written advance directives. She was hospitalized in 1990 for acute pancreatitis. She also had a history of anxiety and depression, which were treated by Haldol and Prozac for several years. She had attempted suicide about 10 years ago. Her husband and daughter (Martha), were supportive. A son was kept out of the decision-making process because of a history of depression and the fear that he may harm himself. Mr. M and Martha voiced agreement that Mrs. M should make her own decision regarding treatment or withdrawal from the ventilator. Mr. M said his wife had spoken about potential end-of-life situations. She was clear that she did not want to be kept alive if the quality of her life would be more compromised than it already was. For the first three days of hospitalization she was aware and responsive. She was presented with the possibility of pancreatic surgery to relieve her from the terrible pain she was experiencing, and told that the surgery was high risk with a 50 percent chance she could die in surgery. Recovery would require extensive respiratory care, which meant time in an extended care facility. She was also informed that she now required dialysis. She declined the surgery and dialysis expressing a desire to be withdrawn from the ventilator. The physician agreed to her request, which had the support of Mr. M and Martha. On the fourth day of hospitalization, the doctor had a conversation with Martha and hesitated on withdrawing the ventilator. He called for an ethics committee consult. He became concerned about Mrs. M's age and potential to rally medically. He was also concerned about her past history of depression, and wondered whether she desired a kind of physician-assisted suicide. He also began to question her competence and/or decision- making capacity. Mr. M and Martha were angered at this decision-making reversal and the consult with the ethics committee. They had told Mrs. M that her decision would be honored and they were in the process of already struggling with the grief that would be inevitable. Such ambivalence caused even more conflict and anxiety. (Adapted from Kuczewski, M. & Pinkus, R. An Ethics Case Book for Hospitals: Practical Approaches to Everyday Cases. Washington D.C.: Georgetown University Press, 1999) PHI 324 - Module 8 Case Analysis Questions The following questions can aid in the process of di.

1. PHI 324 – Case Study
The Case of Mrs. M
Mrs. M was a 54 year-old woman who was transferred to a
tertiary care hospital's critical care unit from a
community hospital. She had been diagnosed with an acute
anterior wall myocardial infarction (heart
attack). Secondary diagnoses were acute pancreatitis,
disseminated intravascular coagulation, acute
respiratory failure, and lactic acidosis. She was placed on a
ventilator. Due to medication and her serious
medical problems, she was only periodically alert, but
responsive when directly addressed. There were
no written advance directives.
She was hospitalized in 1990 for acute pancreatitis. She also
had a history of anxiety and depression,
which were treated by Haldol and Prozac for several years. She
had attempted suicide about 10 years
ago.
Her husband and daughter (Martha), were supportive. A son was
kept out of the decision-making process
because of a history of depression and the fear that he may harm
himself. Mr. M and Martha voiced
agreement that Mrs. M should make her own decision regarding
treatment or withdrawal from the
ventilator. Mr. M said his wife had spoken about potential end-
of-life situations. She was clear that she did
not want to be kept alive if the quality of her life would be more
compromised than it already was.

2. For the first three days of hospitalization she was aware and
responsive. She was presented with the
possibility of pancreatic surgery to relieve her from the terrible
pain she was experiencing, and told that
the surgery was high risk with a 50 percent chance she could die
in surgery. Recovery would require
extensive respiratory care, which meant time in an extended
care facility. She was also informed that she
now required dialysis. She declined the surgery and dialysis
expressing a desire to be withdrawn from the
ventilator.
The physician agreed to her request, which had the support of
Mr. M and Martha. On the fourth day of
hospitalization, the doctor had a conversation with Martha and
hesitated on withdrawing the ventilator. He
called for an ethics committee consult. He became concerned
about Mrs. M's age and potential to rally
medically. He was also concerned about her past history of
depression, and wondered whether she
desired a kind of physician-assisted suicide. He also began to
question her competence and/or decision-
making capacity.
Mr. M and Martha were angered at this decision-making
reversal and the consult with the ethics
committee. They had told Mrs. M that her decision would be
honored and they were in the process of
already struggling with the grief that would be inevitable. Such
ambivalence caused even more conflict
and anxiety.
(Adapted from Kuczewski, M. & Pinkus, R. An Ethics Case
Book for Hospitals: Practical Approaches to Everyday Cases.
Washington D.C.: Georgetown University Press, 1999)

3. PHI 324 - Module 8 Case Analysis Questions
The following questions can aid in the process of discernment
or the gathering and the assessing of the
case.
Facts:
What are Mrs. M’s medical status, diagnosis and prognosis?
How reliable are these?
Has there been a second opinion?
What treatments are possible?
What is the probable life expectancy and condition of the
patient if treatment is received?
What is the probability that treatment will benefit the patient?
Patient Preference:
Is Mrs. M. competent?
Has she been informed about her condition and how?
Has she had time to reflect on treatment alternatives?

4. Has she made a clear statement about her wishes?
Does she have a written statement about her wishes, a durable
power of attorney or living will?
If there is no clear statement, is there anyone who knows what
the patient desire?
Views of Family and Friends:
Are there family members and friends?
Do they understand the patient’s condition?
What is their position and do they agree with one another?
Does any one have primary responsibility or legal custody?
If the patient is a minor, are they choosing what is in the
child’s best interest?
Are there problems of communication with the family or
friends? If so, can someone be found (a
minister) who could help?
Views of the Care Givers:
Are the care givers fully aware of the facts?
What are their views and what are the reasons for them?
If there are differences, what is the cause of these?
How might the differences be resolved?

5. Legal, Administrative and Other Factors:
Are there laws that apply to the case?
Is there potential liability to the providers?
Are there any hospital guidelines that apply, i.e., Catholic
Health Care ethical norms?
Are there others outside the hospital system that should be
consulted?
What literature would it help to consult on this case?
Is expense to the patient and family a factor in this case?