Chapter 3: End-of-Life Care and Decision-Making

Withdrawing Life Support Case Description: A 70-year-old man with terminal lung cancer is on a ventilator in the ICU. His advance directive states no prolonged life support. His wife insists on continuing, hoping for a miracle. Ethical Question: What should the medical team do?

A. Follow the advance directive and withdraw the ventilator.
B. Continue ventilation, respecting the wife’s wishes.
C. Seek a court order to withdraw support.
D. Consult the ethics committee before deciding.

Do-Not-Resuscitate (DNR) Order Conflict Case Description: An 85-year-old woman with severe dementia has a DNR order. During a cardiac arrest, her son demands resuscitation, claiming she’d want to live longer. Ethical Question: What should the team do?

A. Honor the DNR and withhold resuscitation.
B. Perform CPR, as the son requests.
C. Delay and consult the family further.
D. Resuscitate temporarily while reviewing the DNR.

Palliative Sedation Request Case Description: A 60-year-old woman with metastatic cancer suffers unbearable pain despite maximum treatment. She requests sedation to unconsciousness until death. Her family fears it hastens death. Ethical Question: How should the physician respond?

A. Provide palliative sedation, as she requests.
B. Refuse, due to family concerns about hastening death.
C. Offer lighter sedation to balance pain and awareness.
D. Seek a second opinion before proceeding.

Feeding Tube Withdrawal Case Description: A 75-year-old man in a persistent vegetative state has a feeding tube. His daughter, his surrogate, requests its removal, citing his prior wishes. The staff worry about starvation. Ethical Question: What should the team do?

A. Remove the feeding tube, per the surrogate’s request.
B. Continue feeding, as withdrawal feels unethical.
C. Seek a court order to continue feeding.
D. Consult the ethics committee.

Physician-Assisted Death Request Case Description: A 50-year-old man with ALS, in a state where assisted death is legal, asks his doctor to prescribe lethal medication. He’s competent and terminally ill. Ethical Question: What should the doctor do?

A. Prescribe the medication, as it’s legal and his wish.
B. Refuse, citing personal ethical objections.
C. Refer him to another provider who will assist.
D. Delay and explore his reasons further.

Family Disagreement on Hospice Case Description: A 65-year-old woman with end-stage heart failure wants hospice care at home. Her husband agrees, but their children insist on aggressive hospital treatment. Ethical Question: Whose decision should the team follow?

A. The patient’s, as she’s competent.
B. The husband’s, as her spouse.
C. The children’s, as they want treatment.
D. Seek a family consensus.

DNR in Emergency Case Description: A 90-year-old man with a DNR order collapses in public. Bystanders start CPR before paramedics arrive and confirm the DNR via his bracelet. Ethical Question: What should the paramedics do?

A. Continue CPR, as it’s already started.
B. Stop CPR, honoring the DNR.
C. Consult family before stopping.
D. Transport him to the hospital for review.

Pain Management vs. Life Prolongation Case Description: A 55-year-old woman with terminal cancer requests high-dose opioids for pain, knowing it may shorten her life. Her husband opposes, wanting her alive longer. Ethical Question: How should the physician proceed?

A. Administer the opioids, per her request.
B. Refuse, prioritizing life prolongation.
C. Compromise with lower doses.
D. Seek a second opinion.

Withdrawal of Dialysis Case Description: A 60-year-old man with end-stage renal failure decides to stop dialysis, tired of suffering. His family begs the nephrologist to continue. Ethical Question: What should the nephrologist do?

A. Stop dialysis, respecting his decision.
B. Continue dialysis, per family wishes.
C. Delay and assess his mental state.
D. Seek a court order to continue.

Hospice Care Refusal Case Description: A 70-year-old man with terminal liver cancer refuses hospice, wanting to die in the hospital with aggressive care. His family insists on hospice for comfort. Ethical Question: What should the team do?

A. Honor his refusal and provide hospital care.
B. Transfer him to hospice, per family wishes.
C. Convince him to accept hospice.
D. Consult the ethics committee.

Futile Treatment Demand Case Description: An 80-year-old woman with multi-organ failure is dying despite ICU care. Her son demands continued aggressive treatment, though the team deems it futile. Ethical Question: How should the team respond?

A. Continue treatment, respecting the son’s wishes.
B. Shift to comfort care, as treatment is futile.
C. Seek a court order to stop treatment.
D. Transfer care to another provider.

Advance Directive Ambiguity Case Description: A 75-year-old man’s advance directive states “no heroic measures” but doesn’t define it. He’s now unconscious with sepsis, and the team debates antibiotics. Ethical Question: What should the team do?

A. Withhold antibiotics, interpreting them as heroic.
B. Provide antibiotics, as they’re not heroic.
C. Consult the family for clarification.
D. Seek legal advice.

Surrogate Request for Euthanasia Case Description: A 65-year-old woman in a coma has no advance directive. Her husband, her surrogate, requests euthanasia (illegal in their state), believing she’d want it. Ethical Question: How should the team respond?

A. Perform euthanasia, per his request.
B. Refuse, as it’s illegal.
C. Explore his reasoning but maintain care.
D. Consult the ethics committee.

Spiritual Beliefs and End-of-Life Case Description: A 50-year-old man with terminal illness refuses palliative care, believing prayer will heal him. His condition worsens, and his family wants intervention. Ethical Question: What should the team do?

A. Respect his refusal, as it’s his belief.
B. Provide palliative care against his wishes.
C. Convince him to accept care.
D. Follow the family’s request.

Pediatric End-of-Life Decision Case Description: A 10-year-old girl with terminal brain cancer is on life support. Her parents want to withdraw it, but her grandparents demand continuation. Ethical Question: Whose decision should prevail?

A. The parents’, as legal guardians.
B. The grandparents’, as family members.
C. Seek a court order to decide.
D. Continue support until consensus.

Terminal Sedation Ethics Case Description: A 45-year-old man with end-stage pancreatic cancer requests terminal sedation. His doctor worries it’s akin to euthanasia and hesitates. Ethical Question: Should the doctor proceed?

A. Yes, as it relieves suffering and isn’t euthanasia.
B. No, because it may hasten death.
C. Offer alternative pain relief instead.
D. Seek a second opinion.

DNR Miscommunication Case Description: A 60-year-old woman with a DNR order is admitted for surgery. The surgical team, unaware, resuscitates her during a complication. Ethical Question: What should the team do upon discovering the DNR?

A. Continue care, as resuscitation started.
B. Stop aggressive measures, honoring the DNR.
C. Consult the family first.
D. Seek legal advice.

Family Request for Life-Prolonging Care Case Description: An 88-year-old man with advanced dementia is dying naturally. His children demand IV fluids and antibiotics, though he’s comfortable without them. Ethical Question: How should the team respond?

A. Provide fluids and antibiotics, per family wishes.
B. Maintain comfort care, as it’s appropriate.
C. Compromise with minimal fluids only.
D. Consult the ethics committee.

Patient Request to Die at Home Case Description: A 55-year-old woman with terminal illness wants to die at home with hospice. Her husband insists on hospital care for monitoring. Ethical Question: What should the team do?

A. Honor her wish for home hospice.
B. Keep her in the hospital, per her husband.
C. Delay discharge and mediate with the couple.
D. Seek a court order.

Withdrawal of Ventilator in Pediatrics Case Description: A 5-year-old boy with a terminal condition is ventilated. His parents request withdrawal, but the team feels uneasy about ending life so young. Ethical Question: Should the team proceed?

A. Withdraw the ventilator, per parental request.
B. Refuse, citing ethical discomfort.
C. Seek a second opinion.
D. Consult the ethics committee.

Cultural Beliefs Against Withdrawal Case Description: A 70-year-old man from a culture valuing life prolongation is dying. His family refuses withdrawal of futile treatments, citing tradition. Ethical Question: How should the team respond?

A. Respect the family’s beliefs and continue treatment.
B. Shift to comfort care, as it’s futile.
C. Educate the family and seek consensus.
D. Transfer care to another team.

Advance Directive for Pain Control Case Description: A 65-year-old woman’s advance directive requests maximal pain relief, even if it shortens life. She’s unconscious, and her son opposes high-dose opioids. Ethical Question: What should the team do?

A. Follow the directive and use high-dose opioids.
B. Respect the son’s wishes and limit opioids.
C. Compromise with moderate doses.
D. Seek legal advice.

Surrogate Demand for Futile Surgery Case Description: An 80-year-old man with terminal illness is unconscious. His wife demands a risky surgery with no survival benefit, hoping for recovery. Ethical Question: How should the team respond?

A. Perform the surgery, per her request.
B. Refuse, as it’s futile and harmful.
C. Seek a second opinion.
D. Consult the ethics committee.

Hospice vs. Aggressive Care Case Description: A 50-year-old man with end-stage COPD wants hospice, but his wife insists on ICU care, believing he’ll improve. Ethical Question: What should the team do?

A. Honor his wish for hospice.
B. Follow the wife’s request for ICU care.
C. Delay and mediate between them.
D. Seek a court order.

Withdrawal of Life Support in Pregnancy Case Description: A 30-year-old pregnant woman at 20 weeks is brain-dead. Her husband wants to withdraw support, but her parents want to sustain her for the fetus. Ethical Question: Whose decision should prevail?

A. The husband’s, as her surrogate.
B. The parents’, for the fetus’s sake.
C. Seek a court order to decide.
D. Continue support until viability.

DNR in Psychiatric Patients Case Description: A 40-year-old man with schizophrenia and terminal cancer has a DNR order. During a psychotic episode, he demands resuscitation if he arrests. Ethical Question: What should the team do if he arrests?

A. Honor the DNR, as it was made when competent.
B. Resuscitate, per his current request.
C. Assess his capacity now.
D. Consult the family.

Family Request for Comfort Only Case Description: A 90-year-old woman with end-stage heart disease is unconscious. Her children request comfort care only, but the team sees potential for recovery with treatment. Ethical Question: How should the team proceed?

A. Shift to comfort care, per family wishes.
B. Pursue treatment, as recovery is possible.
C. Seek a second opinion.
D. Consult the ethics committee.

Patient Request for No Treatment Case Description: A 60-year-old man with terminal illness refuses all interventions, wanting a natural death. His family demands antibiotics for an infection. Ethical Question: What should the team do?

A. Respect his refusal and withhold antibiotics.
B. Administer antibiotics, per family wishes.
C. Delay and mediate with the family.
D. Seek legal advice.

Advance Directive vs. Medical Judgment Case Description: A 75-year-old man’s advance directive refuses ventilators. He’s now unconscious with pneumonia, and the doctor believes short-term ventilation could save him. Ethical Question: What should the doctor do?

A. Follow the directive and avoid ventilation.
B. Ventilate him, as it’s potentially reversible.
C. Consult the family for input.
D. Seek a court order.

Surrogate Request for Prolongation Case Description: An 85-year-old woman with no hope of recovery is on life support. Her son, her surrogate, demands it continue indefinitely, citing emotional distress. Ethical Question: How should the team respond?

A. Continue support, per the surrogate.
B. Withdraw support, as it’s futile.
C. Seek a court order to withdraw.
D. Consult the ethics committee.

Pain Management in Pediatrics Case Description: A 12-year-old boy with terminal cancer requests more pain medication, risking respiratory depression. His parents fear it will hasten death. Ethical Question: What should the team do?

A. Increase medication, per his request.
B. Limit medication, per parental wishes.
C. Seek a compromise dose.
D. Consult a pain specialist.

DNR in Surgical Context Case Description: A 70-year-old man with a DNR order needs emergency surgery with a high arrest risk. He’s unconscious, and the surgeon questions honoring the DNR intraoperatively. Ethical Question: Should the DNR be followed during surgery?

A. Yes, withhold resuscitation if he arrests.
B. No, suspend the DNR during surgery.
C. Consult the family first.
D. Seek an ethics review.

Family Request for Euthanasia Case Description: A 55-year-old man in a vegetative state has no directive. His wife requests euthanasia (illegal), believing it’s merciful. The team refuses. Ethical Question: Was the team’s refusal ethical?

A. Yes, as euthanasia is illegal.
B. No, because it denies mercy.
C. Yes, but they should explore alternatives.
D. No, they should consult ethics first.

Withdrawal in Religious Context Case Description: A 60-year-old woman’s family, from a faith opposing withdrawal, demands continued ventilation despite her terminal state and prior wish to stop. Ethical Question: What should the team do?

A. Honor her wish and withdraw ventilation.
B. Continue ventilation, per family beliefs.
C. Seek a religious leader’s input.
D. Consult the ethics committee.

Patient Request for Hastened Death Case Description: A 45-year-old woman with terminal illness asks her doctor to hasten her death in a state where it’s illegal. She’s suffering immensely. Ethical Question: How should the doctor respond?

A. Refuse, as it’s illegal.
B. Increase pain medication to indirectly hasten death.
C. Refer her to palliative care for relief.
D. Seek a legal exception.

Surrogate Uncertainty Case Description: An 80-year-old man with no directive is dying. His daughter, his surrogate, is unsure what he’d want regarding life support and asks the team to decide. Ethical Question: What should the team do?

A. Decide based on medical best interest.
B. Continue support until she decides.
C. Shift to comfort care as default.
D. Consult the ethics committee.

DNR in Hospice Case Description: A 65-year-old man in hospice with a DNR order arrests during a family visit. A relative starts CPR, unaware of the DNR. Ethical Question: What should the hospice staff do?

A. Stop the relative, honoring the DNR.
B. Allow CPR to continue, as it’s started.
C. Consult the family further.
D. Call emergency services.

Pain vs. Consciousness Trade-Off Case Description: A 50-year-old man with terminal cancer wants to stay alert for his family but suffers severe pain. High-dose opioids would relieve pain but sedate him. Ethical Question: What should the team do?

A. Prioritize pain relief with high doses.
B. Respect his wish to stay alert with lower doses.
C. Seek a compromise dose.
D. Consult a pain specialist.

Withdrawal in Young Adults Case Description: A 25-year-old woman with a terminal illness is on life support. Her parents, her surrogates, request withdrawal, citing her suffering. The team hesitates due to her age. Ethical Question: Should the team proceed?

A. Withdraw support, per parental request.
B. Refuse, citing her young age.
C. Seek a second opinion.
D. Consult the ethics committee.

Advance Directive vs. Family Grief Case Description: A 70-year-old man’s advance directive requests no life support. He’s unconscious, and his wife begs for ventilation to say goodbye. Ethical Question: What should the team do?

A. Follow the directive and withhold ventilation.
B. Ventilate briefly, per her request.
C. Consult the family further.
D. Seek legal advice.