AJ is a 59-year-old male with a history of poorly controlled diabetes mellitus (type 2), cardiovascular disease, multiple strokes, and end-stage renal failure (dialysis dependent). Patient states he was previously very active, but after his stroke he has been cared for in an intermediate care facility. His course has been complicated by multiple decubitus ulcers, immobility, aspiration pneumonia, and urinary tract infections, resulting in multiple hospital admissions. On this admission, AJ was diagnosed with vancomycin-resistant enterococcal sepsis. When transport arrived to take him to dialysis, he refused, stating "I no longer want to live like this." The attending physician consulted psychiatry who diagnosed major depression and felt patient did not have the capacity to make the decision to withhold treatment. The nephrology team refused to dialyze the patient "against his will." Palliative medicine was consulted to determine surrogacy and to evaluate capacity. AJ expressed understanding of his situation and the consequences of his action stating "I don't want to kill myself, but if I stop dialysis I'll die and that is my wish." AJ also stated "who wouldn't be depressed in my situation?" AJ has no identified surrogate, being estranged from his spouse who was reportedly abusive, and lacked other relatives or friends. The attending physician was assigned surrogate and immediately ordered an ethics consult.
JM is a 32-year-old primagravida with polycystic ovary disease. She had extreme difficulty conceiving and was started on clomiphene 6 months ago by her fertility specialist. After doubling the dose on the sixth cycle, she successfully became pregnant. On her second prenatal visit at 12 weeks gestation, an ovarian cyst was detected. Ultrasound showed a complex ovarian mass with nodules on the bowel and abdominal wall. There was mild-to-moderate peritoneal fluid. Cytology showed adenocarcinoma of ovarian origin. Further workup demonstrated advanced stage III epithelial ovarian cancer. JM was referred to GYN-oncology who felt pregnancy-sparing debulking was not an option. The oncologist recommended termination of pregnancy due to the risks of delaying chemotherapy. JM refused, citing her fertility difficulties in the past and her desire to carry the pregnancy to term “even if it kills me.” She tells the oncologist she cannot bear the thought of terminating her pregnancy under any circumstances. The oncologist wants to comply with her wishes but feels the patient is making a choice that would result in harm to herself. The oncology team requests an ethics consult.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.