Mrs. W is an 81-year-old woman with recurrent colon cancer with liver metastases admitted to the hospital for chemotherapy. Because of her poor prognosis, you approach her about a DNR order, but she requests to be "a full code." Can you write a DNR order anyway?

Mr. H is a 24-year-old man who resides in a skilled nursing facility, where he is undergoing rehabilitation from a cervical spine injury. The injury left him quadriplegic. He has normal cognitive function and no problems with respiration. He is admitted to your service for treatment of pneumonia. The resident suggests antibiotics, chest physiotherapy, and hydration. One day while signing out Mr. H to the cross covering intern, the intern says "he should be a DNR, based on medical futility." Do you agree? Is his case medically futile, and if so, why?

Mr. B is a 46-year-old man who comes into clinic to follow-up on multiple uncontrolled medical problems including diabetes, hypertension, obesity, depression and sleep apnea. He is unemployed and is currently homeless, though had been sleeping regularly on a friend’s couch. He and the friend have been getting into some arguments and he does not feel comfortable staying there anymore, so is sleeping in his car. On further discussion the patient shares that he lost his last job due to recurrent conflict with a co-worker.

Mr. S is a 48-year-old man with a long history of drug and alcohol use. He has continues to drink alcohol regularly though is regularly seeing a substance abuse counselor. He also uses cocaine with some regularity and buys pain pills on the street. Mr. S has chronic pain due to back, shoulder and neck injuries from the past. When he takes a narcotic he feels better, so would like to be on a regular dose of pain medicine. He is seen frequently in clinic, often as a walk-in seeing a variety of providers, and he invariably asks for pain medicine. Mr.

Mr. D is a 64-year-old man with multiple complex medical problems including uncontrolled diabetes, untreated depression, coronary artery disease (status post myocardial infarction with multiple stents), painful peripheral vascular disease, hypertension, hyperlipidemia, chronic hepatitis C, spinal stenosis and ongoing 2 pack per day tobacco use. He is on a long list of 16 medications and insulin, though does not take any of his medications with regularity. Mr. D returns to clinic and all of the above medical problems are not well controlled.

A 3-year-old child is brought to your clinic with a fever and stiff neck. You are quite certain the child has meningitis. When you discuss the need for a spinal tap and antibiotic treatment, the parents refuse permission, saying, "We'd prefer to take him home and have our minister pray over him."

Can the parents refuse treatment in this case? How should you handle this?

A 23-year-old Navajo man has injured his leg after a fall. He presents to the emergency room of the reservation hospital where he is complaining of pain. His leg appears to be broken. The man requests that you call a medicine man before doing anything further.

Should you find a medicine man? Should you proceed with treatment?

Cross-cultural Issues and Diverse Beliefs

Case 1

A mother brings her 18-month-old daughter to your office for a routine physical examination. The child has had no immunizations. Her mother says that they believe that vaccines weaken the immune system and have heard that vaccination can cause autism.

What is your role in this situation? Can parents refuse to immunize their children?