MR.

B, AN 82 YEAR OLD MAN, IS SEEN IN THE EMRGENCY DEPARTMENT (ED) FOR CHEST PAIN, POSSIBLY RELATED TO A MYOCARDIAL INFARCTION (MI). THE ED PHYSICIAN INWUIRES WHETHER MR. B DESIRES CPR IF HE SHOULD EXPERIENCE A CARDIOPULMONARY ARREST.

MR. B TELLS THE PHYSICIAN THAT HE WANTS EVERTHING DONE. FOLLOWING ADMISSION FOR AN EXTENSIVE MI, MR. B DEVELOPS SEVERAL COMPLICATIONS THAT EXTEND HIS HOSPITALIZATON AND REQUIRE ADMISSION TO THE ICU. FOLLOWING A CODE IN THE NEXT ROOM, MR. B ASKS THE NURSE WHAT HAPPENED.

WHEN THE NURSE EXPLAINS THAT THE PATIENT IN THE NEXT ROOM CODED, MR. B BECOMES CONCERNED ANS ASKS WHAT IS DONE TO A PERSON DURING CODE. AFTER THE NURSE DESCRIBES WHAT TYPICALLY HAPPENES DURING CODE, MR. B STATES THAT HE DOES NOT WANT TO GO THROUGH THAT.

HE STATES THAT HE HAS LIVED A GOOD LIFE, HE IS TIRED, AND HE WOULD NOT WANT TO END UP IN A NURSING HOME OR TO BE A BURDEN FOR HIS FAMILY. FOLLOWING DISCUSSION WITH HIS PHYSICIAN, A DO-NOT-RESUSCIATE (DNR) ORDER IS WRITTEN FOR MR. B.

AT THE NEXT FAMILY VISIT, MR. B EXPLAINS TO HIS WIFE AND DAUGHTER THAT HE REQUESTED A DNR ORDER. THE FAMILY BECOMES UPSETAND ASKS THE NURSE WHAT IS GOING ON. THEY EXPLAIN TO THE NURSE THAT THEIR FATHER WOULD WANT EVERTHING POSSIBLE DONE.

SEVERAL FACTORS ARE CONCERN IN THE CASE STUDY. DID MR. B MAKE AN INFORMED CHOICE WHEN HE INITIALLY EXPRESSED HIS DESIRE TO HAVE EVERYTHING DONE? WERE THERE ONGOING DISCUSSIONS WITH MR. B AND HIS FAMILY MEMBERS TO ASCERTYAIN THEIR COMPREHENSION OF THE SITUATION AND THE FACTS?

WHAT ARE THE VALUES, BELIEFS, GOALS, EXPECTATIONS, AND PREFERENCES REGARDING THE CURRENT CIRCUMSTANCES AND POSSIBLE FUTURE EVENTS? ARE MR. B AND HIS FAMILY INFORMED OF THE TREATMENT OPTIONS AND THEIR POSSIBLE OUTCOMES BASED ON HIS CIRCUMSTANCES AND THE AVAILABLE SCIENTIFIC INFORMATON?

DETERMINE THE PROBLEM

1. WHAT IS THE HEALTH PROBLEM? 2. WHAT ARE THE ETHICAL ISSUES? 3. WHAT IS KNOWN ABOUT THE HEALTH ISSUE? 4. WHAT ARE THE AVAILABLE SCIENTIFIC EVEIDENCE?

IDENTIFY THE DECISION MAKERS

1. WHO ARE INVOLVED? 2. WHO SHOULB BE INVOLVED? 3. WHAT ARE THEIR ROLES? 4. WHAT ARE THEIR VALUES AND BELIEFS?

DETERMINE THE CONTEXT

1. WHAT IS KNOWN ABOUT THE SITUATION? 2. WHAT DO WE NEED TO KNOW? 3. WHAT ARE RELEVANT CONTEXTUAL FACTORS? 4. HOW DO WE OBTAIN ADDITIONAL INFORMATION?

FRAME THE ISSUE

1. WHAT ETHICAL PERSPECTIVE? 2. IS THIS PROBLEM PRIMARILY A QUESTION OF BENEFIT VERSUS BURDEN? 3. WHAT IS THE CLINICALLY AND ETHICALLY RELEVANT INFORMATION WITHIN THIS FRAME?

IDENTIFY OPTIONS AND IMPLICATIONS

1. WHAT ARE ALL THE POSSIBLE OPTIONS? 2. WHAT ARE THE IMPLICATIONS OF EACH OPTIONS? 3. WHICH ARE MORALLY CONGRUENT WITH THE VALUES OF THE DECISION MAKERS?

SELECT COURSE OF ACTION

1. 2. 3. 4. WHAT IS THE BEST ACTION? WHAT IS THE ETHICAL REASONING? WHAT IS THE DESIRED OUTCOME? HOW, WHEN AND BY WHOM WILL THE DECISION ANS OUTCOME MUST BE EVALUATED?

EVALUATE THE DECISION

1. WERE THE DESIRED OUTCOMES ACHIEVED? 2. KNOWING WHAT IS KNOWN WOULD BE CHOICE HAVE BEEN DIFFERENT? 3. WOULD THE DECISION BE THE SAME IN THE FUTURE?