THE CASE

Jane, 8 yr old, Leukemia (3 years ago)

She was diagnosed 3 years ago. Initial chemotherapy
brought remission for a year. However, last year there
was a recurrence and the two cycles of chemotherapy
did not stop the progression of the disease. This
admission she was given a new combination of drugs.
One of the drugs caused an anaphylactic reaction on
the second week and had to be discontinued. Her bone
pains had increased and is now on full dose analgesics.
Lumbar Tap showed meningeal infiltration by the
leukemic cells.

 On her 4th week, she had generalized seizures,

anti-convulsants were given, which did not
immediately control her seizures, her last one
lasting 30 minutes (status epilepticus). She was
intubated and maintained on ventilator, while
waiting to assess her brain status. She remained
unresponsive for the next 5 days. Her parents
wanted to bring her home but the maternal
grandmother who financially supports for the
child refused and asked the doctors to do
everything possible for Jane.

PROBLEM
Problem: Patient is in critical care,
mechanically ventilated with brain status
unknown. Parents are opting for home care
whereas grandmother wants hospital care.

ISSUES
1. Parents are next-in-line proxies for surrogate
decision making instead of grandmother so
finality of which care is their prerogative.
2. Patient is unresponsive for 5 days and
mechanically ventilated.

REVIEW OF ETHICAL GUIDELINES

Patients with severely impaired consciousness

are most likely to be treated in an acute care
hospital where focus is primarily on saving their
life and stabilizing them medically. Hospitals will
start discharge planning as soon as lifethreatening
medical
problems
have
resolved. Despite being intubated, patients who
are in a vegetative state are able to leave the
hospital when they become stable medically.
Next focus is on recovery of function to whatever
level is possible in an acute rehabilitation
hospital.

REVIEW OF ETHICAL GUIDELINES

Decisions to change levels of treatment should
reflect an assessment of whether current
treatment is likely to achieve the goals set for
it and whether the benefits or prospective
benefits of treatment are outweighed by its
burdens.