Reference no: EM133234533

Case 1 Goal-directed Interventions (option 1)

Martha Simms was admitted to the hospital in a coma for treatment of pneumonia and respiratory failure. Mrs. Simms, 62-years-old, has managed her multiple sclerosis (MS) relatively well since its onset thirty years ago. Over the past 15 years or so, as her condition has deteriorated, she has stressed to her family and physicians that she does not wish to be placed on permanent mechanical ventilation nor does she wish CPR (cardiopulmonary resuscitation) once it becomes clear that she has "little time left."

After Mrs. Sims is stabilized on the mechanical ventilator, neurologic consultation concludes that her respiratory insufficiency is secondary to the advancing muscular and neurologic deterioration of end-stage MS and that her irreversible respiratory failure was accelerated by her acute pneumonia.  The health care team explains that Mrs. Simms's death is almost certainly imminent and that various efforts that constitute CPR will not alter the inevitable, just prolong the dying process a short while. The neurologist does not anticipate Mrs. Simms regaining consciousness. The ICU attending physician recommends discontinuing respiratory support, since this appears to have no outcome beyond prolonging the pt's dying.

Mrs. Sims' husband and three adult children are adamant that "everything be done" for her, including resuscitation when her heart stops. Mr. Simms and his children remain adamant that a DNR (Do Not Resuscitate order) not be written in the chart.

What interventions are medically indicated for Mrs. Simms? Why?  Are any interventions not indicated or contra-indicated? Why?

• Note that medical indications are distinct from patient preferences: medical indications often shape or influence patient preferences, but patients sometimes refuse medically indicted care or request care that is not medically indicated.
• Hint: If you state an intervention is medically indicated, then (1) you should be able to identify a general goal of medicine that is supported by the intervention and (2) the intervention should have a reasonable chance of achieving that goal. In other words, if you contend that an intervention will "help" a patient, then be prepared to clarify how--by preventing an untimely death, by restoring health or physical functions, by relieving suffering, etc.