1. Position of the ED physician Terea McCarthy

2. The dilemma is what type of treatment, if any to provide for Helen.

3. Helen’s history reveals: 46 year old, female HIV + for 15 years lymphoma of the brain cytomegalic retinitis Kaposi's sarcoma of the thigh and groin (treated with radiation 2 months ago) In hospice care

4. Examination reveals: Deep Vein Thrombosis of the left thigh

5. The ED physician and the hospice physician have differing medical opinions as to what course of action should be taken for Helen. They both agree that should the clot dislodge it could be potentially fatal.

6. The ED physician recommends surgery for Helen. He believes that surgery is the best option for Helen considering her extenuating medical problems. He understands that the surgery will not “save” her life ultimately. He is practicing the concept of palliative care, which is a benefit to the patient. Attempting to relieve pain and ease the suffering of the patient.

7. The hospice physician disagrees with this plan of care. His stance is that death may occur if the clot dislodges. His opinion is that would be a better death with less suffering than for Helen to endure the sequelae of AIDS and convulsions from the brain tumor. Is doing nothing an act of maleficence? Meanwhile, Helen has been transferred back and forth with no benefit received.

8. Where is Helen in this process? Isn’t this her decision, if she is competent to make it? What about her family if she has any? Also does she have an advanced directive? Does she have a medical power of attorney?

9. The following should be involved when this decision is being made. Helen Her family Her physicians Advanced directive ,if applicable Medical Power of Attorney, if applicable

10. Helen, if unable to make decisions at this time, may have already made provisions for her wishes. She has had knowledge of her disease process for an extended length on time. Her wishes if known, should be honored.

11. Maybe you are thinking that medical futility should come into play at this point. “Futility refers to the benefit of a particular intervention for a particular patient. Does this intervention have ANY reasonable prospect of helping this patient?” http://depts.washington.edu/bioethx/topics/ futil.html 6/20/2010

12. The ED physician’s plan of care is the one that offers the most benefit to Helen. It has reasonable prospect for helping her. Pain Relief Decreased probability of clot dislodgement. Opportunity for a few more “good” days

13. We know that Helen is terminal. Terminal can last a long time in some instances. The truth is no one knows how long their end of life stage will be, nor anyone else’s.

14. Hospice care philosophy is described as “You matter because you are you. You matter to the last moment of your life and we will do all we can, not only to help you die peacefully but to live until you die.” www.avert.org/palliative-care.htm 6/20/2010 Is the hospice physician really embracing this philosophy in his care of Helen? I think NOT!