1) The dilemma is whether surgical intervention or anticoagulant treatment is best for Helen, a hospice patient with a terminal illness, to provide a more humane dying process. 2) The hospice physician recommends anticoagulant therapy to allow a more peaceful death, while the ER physician wants surgery. 3) The best alternative is to ask Helen her preference, or if unable, her next of kin, and administer anticoagulants as the hospice physician advocates, to avoid prolonging her suffering from her terminal illness.

1. Dilemma #3 Side A: Explain the position of the hospice medical director Amie Starks ***To open web pages, right click, then choose ‘open hyperlink’ option.

2. What is the dilemma? The dilemma is whether or not surgical or anticoagulant treatment is best for Helen, considering she is on hospice and has a terminal illness. Which intervention would cause the patient a more humane dying process, considering death is anticipated either way?

3. Who needs to be involved? The patient (most importantly) The hospice physician The ER physician The family (if allowed by the patient) Ethics Committee, if available Any spiritual or religious advisor to the patient (preacher, priest)

4. Meet Helen….The center of our debate http://www.timescolonist.com/travel/asia

5. Alternatives? One alternative to this scenario would be to try the anticoagulants for a couple days, repeat labs and doppler, then re-assess the situation. If improvement is noted, continue current POC. If anticoagulant therapy is unsuccessful, then surgical intervention can be discussed.

6. A second alternative would be to ASK THE PATIENT what she wants. Helen may not even want the surgical intervention. She may choose to let life run its course, and risk death from the DVT rather than HIV. She, more so than an Ethics committee, should determine her plan of care, if able. To help her make that decision, she might speak with family, friends and spiritual advisors. Maybe the hospice physician has already spoken to Helen and knows her wishes. Acting as her advocate, he recommends the anticoagulants, rather than surgery, to allow her a more peaceful death. Maybe she has a living will or DNR in place? Maybe she’s already stated she wants no surgical intervention?

7. Relevant facts Facts We as nurses, know that a DVT can be fatal The ER physician wants surgical intervention Hospice physician wants anticoagulant therapy Helen has had HIV for 15 years and probably will have a painful, prolonged death process, which the hospice physician is trying to avoid She has multiple complications from HIV already (lymphoma, retinitis, Kaposi's sarcoma)

8. Assumptions We assume that Helen’s opinion has not been considered or included, since there is no supportive documentation As mentioned earlier, how do we know she even wants the surgery? How does she feel about prolonging the death process? Maybe she is suffering now, and just wants an uncomplicated, quick death process. By performing the surgery, we would just prolong her suffering.

9. We assume that a surgeon would do the procedure How do we know that after appraising the situation, the surgeon wouldn’t refuse to perform the surgery, considering her terminal illness. Would he agree with the Hospice physician, and help Helen have a more humane dying process? How do we know that Helen’s current condition wouldn’t prevent a surgery at this time (low blood pressure, low blood counts, etc)? http://www.avert.org/stages-hiv-aids.htm

10. Greatest Good-vs-Least Harm Questions to ponder: Is performing a surgery that has the likely potential to cause death anyway, not the same as letting her die from the DVT? If the surgery was done, and Helen acquired an infection (causing multi-systemic failure because of lack of an immune system to combat infection), would the death process not be just as painful as dying from AIDS?

11. Ethical Code of Conduct The NAHC Ethical Code of Conduct states that a patient has the right to “refuse treatment within the confines of the law and to be informed of the consequences of his action”. This means that Helen must be made aware that having the surgery could lead to a longer life but with possible prolonged suffering, and not having the surgery could mean a more peaceful death, as advocated by the hospice physician. If Helen is not mentally able to comprehend this information, due to brain lymphoma, then a family member, if available, should be informed. http://www.nahc.org/FAQs_ethics.html

12. What is the best alternative? ASK THE PATIENT!!!! If she is unable to make her own medical decisions, ask the next of kin or POA. If no one is available, then I agree with the hospice physician, that the best alternative is to administer only the anticoagulants at this time. Recheck labs and doppler the left thigh again in two days. If no improvement is noted, then let the natural death process occur.

13. You may ask….What if the clot dislodges and causes MI, CVA or PE? My argument is this…. The pains associated with MIs, CVAs, and PEs are short-lived. Although intense, they are still short-lived, and don’t subject the patient to prolonged pains. The patient may experience pain, but this pain is still less suffering than the ravaging effects of AIDS. She will not have to feel the prolonged pains of starvation from the malnutrition effects of AIDS, or the prolonged struggle for breath associated with severe pneumonia, caused by Kaposi’s sarcoma. Nor will she have to experience the pain of seizures and their consequences caused by the brain lymphoma. I believe this course of action would provide better odds for Helen to have a quick, uncomplicated, peaceful death. View some of the side effects of AIDS progression at the website provided, and you might agree with the hospice physician. The side effects are very sad, and leave no quality of life for the patient. http://www.mayoclinic.com/health/hivaids/ds00005/dsection=complications

14. Something to think about: The ER physician usually makes decisions for people that will get well, go home, and live normal lives. He does not normally provide care to terminally ill patients. The hospice physician takes care of patients like Helen everyday, sees their suffering, and does whatever is within his power to decrease that suffering.

15. Conclusion We can offer Helen adequate, appropriate care without prolonging her suffering and death, by administering the anticoagulants and withholding surgery. Regrettably, we can surmise, Helen will die either way. We can relate with the hospice physician’s stand, because he is acting as Helen’s advocate and giving her an option for a quicker, less painful death.