Click here for Case Study 1 - Mr W

Click here for Case Study 2 - Baby X

Case Study 1 - Mr W

Mr W is a 77 year old in patient. He had major surgery for lung cancer 10 weeks ago and has made no real progress since.  He has suffered from on-going delirium, aspiration pneumonia, and inoperable biliary obstruction. 

He has repeatedly removed an intravenous feeding tube.  The site is now infected and obstructed.  The tube cannot be re-inserted. There is no reasonable prospect of improvement even if the current feeding difficulties can be overcome.

The management approach has been approved by a gastro enterologist of the DHB in which Mr W is a patient, and has also been reviewed by a clinically appropriate specialist from a neighbouring DHB.  All agree that all reasonable options have been explored and this man should be provided with palliative care only.  If the current management approach is maintained, Mr W is likely to die within one or two days.

Mr W’s wife and one of his two sons are happy with the current management plan.  However, another son  insists that his every means of prolonging his father’s life, no matter how remote or unlikely, should be offered.  This son is currently overseas.  There is some uncertainty about whether he is making immediate efforts to return to New Zealand, or, if he is, when he might arrive.

Mr W does currently have a nasal gastric tube in place and because of his current weakened state is no longer trying to remove it.  The tube is not currently being used to provide fluids, but could potentially be used for this purpose.  The external specialist who reviewed the case has written:

"Fluids could be given via the NG tube.  In my view, however, this would make no difference to the ultimate outcome for the patient.  It may prolong his period of discomfort."

Normally unnecessary tubes would be removed during the palliative care stage and this is likely to be discussed with wife this afternoon.  The Clinical Ethics Advisory committee is asked to give an opinion on:

1. Is there always an ethical responsibility to provide fluids and nutrition to an individual when it is possible to do so?

2. Should the hospital prolong Mr W’s life in order to allow his son, currently overseas, to confer in person about appropriate treatment?

3. Should the hospital prolong Mr W’s life if there is any chance, no matter how small, that his condition will improve spontaneously?

4. Is it ethically appropriate to remove tubes that could potentially provide a source nutrition/hydration that would prolong his life?

5. Whether there are any other significant ethical issues not raised by these questions?

Case Study 2 - Baby X

Baby X has come to New Zealand with her twin sister and mother from one of the Pacific Islands. The trio came to New Zealand because Baby X’s twin was born with transposition of the great vessels.  The family are not New Zealand residents and plan to return to their home in the future. There are 4 older siblings still at the Pacific Island home with the father.  The family live in a remote area, far from their local medical facility and even further from the main hospital.  The family are not currently contactable due to the remoteness of their home and a recent cyclone.

Baby X’s sister has had definitive surgery, and is doing well .

During routine examination it was discovered, however that Baby X has complex cyanotic congenital heart disease.  Baby X’s clinician described her condition as follows:

“Saturations noted on arrival to be 70%. Weight 2.7 kg , audible murmur Echocardiogram has revealed complex congenital heart disease with, rather than two ventricles and two inlet valves, only a single right ventricle and common atrioventricular valve (valve between the collecting chambers in the heart and the pumping chambers).  The outflow to the lungs (pulmonary artery) is severely narrowed, both below, and at the level of the pulmonary valve.  Pulmonary arteries are small (3mm).  Both the aorta and the pulmonary artery arise from the single ventricle.  The drainage from the lungs, comes back to the heart in an unusual position, laterally on the common atrium, so that there will be the possibility of developing narrowing of the veins as the child grows. The baby also has asplenism”

In the opinion of her clinical team, Baby X will certainly die in the short term if no surgery is offered, but would require multiple complex and dangerous procedures to have any possible chance of survival to early adulthood in ideal circumstances.

Baby X would require a 3 stage procedure: a shunt now, a Glen n 4-5 months, and a Fontan at about age 4yrs.  These procedures require extensive follow up ,monitoring, cardiac catheterizations, management of anticoagulation, and easy access to good medical attention, to cope with the complications that undoubtedly would occur.  Under ideal conditions, the procedures promise only modest prospects of survival into adulthood.