An elderly man who lives in a nursing home is admitted to the medical ward with pneumonia. He is awake but severely demented. He can only mumble, but interacts and acknowledges family members. The admitting resident says that treating his pneumonia with antibiotics would be "futile" and suggests approaching the family with this stance.

Do you agree?

An elderly patient with irreversible respiratory disease is in the intensive care unit where repeated efforts to wean him from ventilator support have been unsuccessful. There is general agreement among the health care team that he could not survive outside of an intensive care setting. The patient has requested antibiotics should he develop an infection and CPR if he has a cardiac arrest.

Should a distinction be made between the interventions requested by the patient? Should the patient’s age be a factor?
 

A young accident victim has been in a persistent vegetative state for several months and family members have insisted that "everything possible" be done to keep the patient alive.

What are your professional obligations?

Angela is a 72-year-old woman with end stage congestive heart failure from coronary artery disease--she has had two myocardial infarctions. When her medical management is optimal, she is just able to take care of herself in her own apartment, but with any small decompensation, she ends up in the hospital. She comes in for a clinic visit, and her weight is up 2 kilograms and she is complaining of paroxysmal nocturnal dyspnea, even though she has been taking her meds as prescribed. Exasperated and discouraged, she asks, "Am I dying?".

Skip is a 50-year-old man with metastatic nonsmall cell lung cancer. He decided to try palliative chemotherapy because "otherwise I might just as well roll over and give up." After the first cycle of carboplatin and taxol, he requires hospitalization for fever and neutropenia (a complication of the chemotherapy). You stop by for a visit, and he says he feels terrible, wonders "if the chemo is worth all this", but that he's too scared to stop.

After a goal oriented conversation, Mrs. W continues to request to be fully resuscitated in the setting of cardiopulmonary arrest. However, several days later, despite a worsening clinical condition, Mrs. W still requests to be a "full code." Your intern suggests that you sign her out as a "slow code." Should you do this?