medical ethics and faith factor

1. P R E S E N T E D B Y: D E V O R A A B R E H A M
M O D E R AT O R : D R . T E S F AY E
MEDICAL ETHICS
CASE 5.10
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09/02/2023

2. Earl is sixty-three years old and has been on hemodialysis for
about one year because of renal failure resulting from his long
standing diabetes. He also has a history of coronary artery
disease, stroke, and early dementia. He has had several
infections in his indwelling dialysis shunts ( often called “line
infections”), resulting in three admissions to the ICU in the past
year with ventilator support. He was admitted from his nursing
home yesterday with another episode of sepsis from a line
infection. His shunt was removed and he has been stabilized
overnight. He was scheduled to have a temporary dialysis
catheter inserted today. Consent had been given by his wife, but
the patient said he didn’t want it and physically resisted
insertion by Dr. Chandler.
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09/02/2023

3. His wife reports that Earl was a farmer and cheese maker who
has been disabled for 25 years from his diabetes and heart
disease. He did quite well until about two years ago when he
became unable to walk and developed frequent urinary infections.
She describes him as a quiet, private person who loved his three
children and several grandchildren. Two children are living close
by. The other, Jimmy, died of an apparent heart attack while
driving four years ago; he was a close pal of the patient.
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09/02/2023

4. Both Dr. Chandler and Earl’s wife report that he has been
ambivalent about dialysis since it started, and since he was admitted to
the nursing home four months ago, has frequently said he wanted to
stop. He otherwise settled into the nursing home routine better than
expected. Dr. Chandler has cared for Earl for some time. He believes
that Earl still has decision-making capacity in spite of his early
dementia.
His wife told Dr. Chandler that Earl told her this morning he wanted
to stop dialysis and die unless he could have a kidney transplant,
preferably using one of her kidneys. She has hypertension and diabetes
and thus is not a candidate for kidney donation. Transplantation was
discussed early on, and it was acknowledged that patients report a
better quality of life after transplant than while on dialysis. However, it
was not felt to be an option for Earl because of his other medical
problems
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09/02/2023

5. I spoke with Earl in the presence of his wife, his medical
resident and his nurse. He consistently nodded yes and no to
multiple questions and clearly indicated he didn’t want the line
reinserted and didn’t want any more dialysis. When asked what
would happen without dialysis he said, “ l’ll die.” He was
unwilling to verbalize a reason why he wanted to stop now, but
with “20 Questions” said it was not because of pain or other
correctable symptoms, but because life on dialysis was not good
enough. When his wife asked if it was so he could join Jimmy, he
nodded his head, burst into tears, and said to her, "That's mean!"
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09/02/2023

6. • Is it ethically permissible to replace an intravenous line
for hemodialysis over the objection of the patient?
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09/02/2023

7. DISCUSSION POINTS
• Which principle of medical ethics should be taken into
consideration in this case?
• When a patient with decision-making capacity refuses a
lifesaving intervention or refuses to continue life-
sustaining technology, what are the important points that
should be addressed?
• What factor can one consider that led the patient to have
made this decision?
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09/02/2023

8. RECOMMENDATION
1) 
If his caregivers believe all efforts at optimizing his
quality of life have been exhausted, it would be ethically
permissible to honor this man's request to stop dialysis.
2) 
If there is concern that a treatable depression may be a
factor in the timing of his decision, it might be appropriate
to try a short course of a rapid-acting mood stimulator.
Unless there is a significant likelihood of improving his
mood sufficiently to accept continued dialysis, it would be
ethically troublesome to impose line reinsertion and dialysis
over his objection.
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09/02/2023

9. FOLLOW UP
• Earl continued to say he wanted transplantation, though
his nephrology consultant feels he is not a good
candidate. The transplant surgeon was willing to
reconsider his candidacy and said he would pursue an
outpatient evaluation. Earl was willing to continue
dialysis until a determination about transplantation could
be made. He was discharged back to the nursing home.
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09/02/2023