A Legal and Ethical Dilemma Contributed by Alan S. Whiteman, PhD, FACMPE, and Lisa E. Sliney, MS, LNHA, Barry University Background Mary Evelyn Greene, who has memory impairment, lives in a private room at Shady Brook Skilled Nursing Facility located in a beautiful suburb of a major metropolitan city. She has resided at Shady Brook for the past 18 months. Before moving into Shady Brook, Mrs. Greene lived independently in her own home with assistance from a private-duty nursing assistant and a housekeeper. She and her husband had resided together in this home for more than 50 years. Mrs. Greene is 89 years old and suffers from several health problems associated with aging. Mrs. Greene has one son, David Greene. David has the power of attorney to handle his mother’s health care and other personal affairs. David works as a trial attorney in one of the city’s largest and most prestigious law firms. He owns a large home in an upscale neighborhood and works hard to put two of his children through college and another one through medical school. His home is about an hour’s drive from his workplace and about 20 minutes from Shady Brook. David’s wife Barbara has never been close to her mother-in-law and has not shown much interest in her care. Hence, caring for his mother has become a major responsibility for David, and he is having a difficult time dealing with her declining health and the onset of mild dementia. It is becoming increasingly more difficult for David to leave his law practice or the court room to deal with issues related to his mother. Mrs. Greene’s husband was a very successful land developer who left her with a substantial estate, which meets all of her financial needs. After her husband passed away, Mrs. Greene decided to remain in her home. She was able to maintain her independence until she was 87 years old, when she began to show signs of dementia. Shortly thereafter, David moved her to Shady Brook. David also hired a part-time “sitter” to keep her mother company because she was too weak to go out of her room on her own. Mrs. Greene seems to enjoy the sitter’s company and likes the attention she gets. Upon entering Shady Brook, Mrs. Greene became depressed over losing her independence and her home and felt a growing frustration with forgetfulness. She gradually lost her appetite, and her desire to eat continued to decline. On the other hand, Mrs. Greene seems to enjoy the smell of certain foods. The associates monitor and document her food intake and her facial expressions when she is offered different foods. Mrs. Greene is particularly fond of Susan Brown, a certified nursing assistant (CNA), who sits with her and helps Mrs. Greene with whatever little she can eat. When this occurs, her appetite shows some improvement. Mrs. Greene also responds well to volunteers who carry out activities at the facility. Frustrated Family Member Mrs. Greene has become too weak to eat on her own. When no one is feeding her, she leaves most of her .

1. A Legal and Ethical Dilemma
Contributed by Alan S. Whiteman, PhD, FACMPE, and Lisa E.
Sliney, MS, LNHA, Barry University
Background
Mary Evelyn Greene, who has memory impairment, lives in a
private room at Shady Brook Skilled Nursing Facility located in
a beautiful suburb of a major metropolitan city. She has resided
at Shady Brook for the past 18 months. Before moving into
Shady Brook, Mrs. Greene lived independently in her own home
with assistance from a private-duty nursing assistant and a
housekeeper. She and her husband had resided together in this
home for more than 50 years. Mrs. Greene is 89 years old and
suffers from several health problems associated with aging.
Mrs. Greene has one son, David Greene. David has the power of
attorney to handle his mother’s health care and other personal
affairs. David works as a trial attorney in one of the city’s
largest and most prestigious law firms. He owns a large home in
an upscale neighborhood and works hard to put two of his
children through college and another one through medical
school. His home is about an hour’s drive from his workplace
and about 20 minutes from Shady Brook. David’s wife Barbara
has never been close to her mother-in-law and has not shown
much interest in her care. Hence, caring for his mother has
become a major responsibility for David, and he is having a
difficult time dealing with her declining health and the onset of
mild dementia. It is becoming increasingly more difficult for
David to leave his law practice or the court room to deal with
issues related to his mother.
Mrs. Greene’s husband was a very successful land developer
who left her with a substantial estate, which meets all of her
financial needs. After her husband passed away, Mrs. Greene
decided to remain in her home. She was able to maintain her
independence until she was 87 years old, when she began to
show signs of dementia. Shortly thereafter, David moved her to

2. Shady Brook. David also hired a part-time “sitter” to keep her
mother company because she was too weak to go out of her
room on her own. Mrs. Greene seems to enjoy the sitter’s
company and likes the attention she gets.
Upon entering Shady Brook, Mrs. Greene became depressed
over losing her independence and her home and felt a growing
frustration with forgetfulness. She gradually lost her appetite,
and her desire to eat continued to decline. On the other hand,
Mrs. Greene seems to enjoy the smell of certain foods. The
associates monitor and document her food intake and her facial
expressions when she is offered different foods. Mrs. Greene is
particularly fond of Susan Brown, a certified nursing assistant
(CNA), who sits with her and helps Mrs. Greene with whatever
little she can eat. When this occurs, her appetite shows some
improvement. Mrs. Greene also responds well to volunteers who
carry out activities at the facility.
Frustrated Family Member
Mrs. Greene has become too weak to eat on her own. When no
one is feeding her, she leaves most of her food on the tray.
Recently, she has sustained a weight loss of more than 5 pounds
per week. Her plan of care needs to be reevaluated, and her
situation needs immediate attention.
David has been visiting his mother quite regularly. Recently,
however, his visits have become less frequent, generally two to
three times per week. The associates who work on Mrs.
Greene’s nursing unit have reported some changes in David’s
attitude. At one time he became angry with his mother, raised
his voice, and spoke to her as if she were a bad child. Although
no one was present in Mrs. Greene’s room at the time, the
associates working at the nursing station heard David’s loud
voice. When the charge nurse went into Mrs. Greene’s room to
find out why David was angry, David told her that it was none
of her business. On David’s subsequent visits, the associates
observed that Mrs. Greene would become agitated during
David’s visits. These issues were brought to the charge nurse’s
attention, and they were documented in the patient’s medical

3. record.
The Dilemma
One day David approached the charge nurse and exclaimed that
his mother had expressed that she wished to die. On his next
two visits, David also told the CNAs that his mother’s desire
was not to eat anything so she could just die a quick death. This
was the first time the CNAs had heard that Mrs. Greene had
expressed a desire to die. The associates also believed that Mrs.
Greene appeared to be happier when David was not there.
Before the week was over, David came into the facility early in
the morning on his way to work. He handed a sealed envelope to
the incoming charge nurse on the day shift. The envelope was
addressed to Betty Wright, Shady Brook’s administrator. David
said to the charge nurse, “I have been telling you people that my
mother wishes a speedy death. Tell your administrator that I
will be filing a lawsuit if my mother’s wishes are not carried
out.” David left without visiting his mother.
Betty Wright decided to place the issue on the ethics
committee’s agenda for that same afternoon. As a safeguard,
Betty also notified the facility’s liability insurance carrier of
the potential legal action.
Meeting of the Ethics Committee
That afternoon, Betty met with members of the ethics
committee: chaplain, medical director, director of nursing,
charge nurse, social worker, two CNAs, and the local
ombudsman. Betty began the meeting with these remarks: “The
man’s mother has been declining rapidly and eats very little. He
wants his mother to die rather than prolong her suffering. I have
learned that the son is the heir to his mother’s estate, and my
overall concern is my trust in his decision or his motives. I
think he needs the money to pay for the college expenses for his
three children. Although it is not uncommon for some residents
to be ignored by family after they are admitted, it is rare that
they express the wish to enable the death of a relatively healthy
person.” The ethics committee is faced with the issue of what is
legally and ethically appropriate. The committee deliberates on

4. whether or not to comply with David’s request to withhold food
as well as the threat of a lawsuit.
Assignment
1. In a sentence or two, identify the main issue.
2. Outline the facts pertaining to this issue.
3. Identify alternative solutions that the ethics committee
might consider.
4. What may be the consequences of the alternatives you have
proposed? Discuss the consequences from the perspectives of
(a) Mrs. Greene and (b) Shady Brook.
5. Discuss the alternatives from the standpoint of the patient’s
rights.
6. What will be your recommendation to the ethics
committee?
7. In their deliberations, should the committee members take
into consideration Betty’s comment that David needs the money
to educate his children?