Case Study 1: Ms. Steinberger has multi-system organ failure and massive intestinal necrosis (dead gut). She is expected to die despite aggressive therapy. As the spokesperson for the interdisciplinary team caring for Ms. Steinberger, what should you discuss first when you talk with the patient?

A. Explain Do-Not-Resuscitate (DNR) orders.

B. Recommend a palliative care treatment plan.

C. Explain the various treatment options.

D. Clarify the goals of care.

Case Study 2: Mr. Santos has end-stage Alzheimer's disease that has left him bed bound and unable to interact. Mrs. Santos, the patient's wife and authorized surrogate, has discussed treatment goals with the health care team, and all are agreed on a plan for comfort care only.
How should the physician handle DNR orders?

A. The physician should write a DNR order.

B. The physician should notify Mrs. Santos that he is going to write a DNR order, and make sure she does not object.

C. The physician should explain to Mrs. Santos what is meant by a DNR order, recommend a DNR order as the best way to achieve the goal of comfort care, and make sure she does not object.

D. Discuss the risk and benefits of CPR and ask Mrs. Santos if she wants her husband to be resuscitated in the event of cardiac arrest.

Case Study 3: Mr. Small is an 84-year-old WWII Veteran who lacks decision-making capacity due to multiple strokes. After a brief hospitalization, he is admitted to a long-term care facility where you are his nurse. The nursing student assigned to you asks, "I noticed Mr. Small has an advance directive. Should we ask the doctor to write a DNR order?" What should you do?

A. Make sure the doctor is aware that the patient has an advance directive.

B. Read the advance directive and determine whether it applies in the patient's current clinical circumstances.

C. Explain to the student that she shouldn't assume Mr. Small wants to forgo cardiopulmonary resuscitation just because he has an advance directive.

D. All of the above.

Case Study 4: Mr. Shapiro completed an advance directive consisting of a living will, in which he specified his preferences regarding certain life-sustaining treatments. Although he has several close relatives, he did not designate a health care agent to make decisions on his behalf. He has multiple medical problems, including COPD, currently lacks decision making capacity, and his respiratory status is tenuous. Imagine you had to decide whether to begin mechanical ventilation, if it should become necessary. What should you do first?

A. Write orders to carry out the patient's wishes as expressed in the advance directive.

B. Read the directive to determine whether it applies under the current circumstances and if so, what the patient would want, then write orders to carry out the patient's wishes.

C. Identify a surrogate and ask that person what should be done for the patient.

D. Identify a surrogate, review the advance directive with the surrogate, and collaborate with the surrogate to arrive at treatment decisions that are consistent with the patient's wishes as articulated in the directive.

Case Study 5: Mr. Stern has Parkinson's disease and has diabetes. One week ago he suffered a serious stroke, and as a result he cannot swallow safely. An NG tube (which goes through the patient's nose into his stomach) is in place for the administration of medication. The GI (gastroenterology) consult recommends beginning tube feedings. If you had to make a decision in this case what would you do?

A. Begin artificial nutrition and hydration through the NG tube.

B. Explain to Mr. Stern that you need to convert the NG tube to a percutaneous endoscopic gastrostomy (PEG) tube (which goes through an incision in the patient's abdomen into his stomach and small bowel) so that nutrition and hydration can be artificially administered on a long-term basis.

C. Ask Mr. Stern whether or not he would like to receive artificially administered nutrition and hydration.

D. Explore with Mr. Stern his goals of care and discuss whether or not artificially administered nutrition and hydration seem right for him.

Case Study 6: Ms. Sheppard is 46 years old and has breast cancer metastatic to the bone and liver. She doesn't want the nurses to change her bed sheets because it worsens her pain when they move her. Ms. Sheppard is already on a very high dosage of morphine, and her physician is concerned that higher doses may cause her unwanted side effects, or even hasten her death. What should the interdisciplinary team caring for Ms. Sheppard do?

A. Change Ms. Sheppard's sheets only if necessary.

B. Give an extra dose of morphine before each bed change.

C. Increase the dose of morphine until Ms. Sheppard no longer experiences any pain.

D. Discuss pain management options with Ms. Sheppard and manage her pain in accordance with her wishes.

Case Study 7: Mr. Allen is a 73-year-old Korean War Veteran with a history of squamous cell carcinoma of the lung and COPD who has been admitted for shortness of breath. He has an advance directive and a DNR order. You're at the nursing station and the nurse's aide tells you that Mr. Allen has just reported that his shortness of breath is much worse. His blood gas results indicate impending respiratory failure.
What should you do?

A. Order 5-10 mg of IV morphine as needed for shortness of breath, and call his family.

B. Call respiratory therapy STAT, and arrange transport to the ICU.

C. Send a respiratory therapist and a nurse to his bedside while you check his advance directive.

D. Go see him and discuss the options.

Case Study 8: Mr. Fiebach is an 83-year-old man with end-stage liver failure. He is confined to bed and needs assistance with all of his activities of daily living. His wife asks about the possibility of hospice care. How do you respond?

A. Tell her that since his prognosis cannot be predicted with certainty, he is not a candidate for hospice.

B. Offer to transfer him to an inpatient hospice bed when one becomes available.

C. Offer to arrange home care with a hospice provider in the community.

D. Determine whether he meets the eligibility criteria for hospice care.

Case Study 9: Stanley Shield is a 53-year-old Vietnam Veteran with a three-year history of amyotrophic lateral sclerosis (Lou Gehrig's disease). He had been cared for at home by his wife until recently, when he began to experience shortness of breath. He had decided against mechanical ventilation, and is expected to die soon of respiratory failure. You and your team have just finished reviewing his case outside his door on morning rounds. What should you do next?

A. Don't burden him with routine visits; move on to the next patient.

B. Assign one person from the team to come back and visit Mr. Shield later.

C. Knock on the door, pause a moment, then enter as a team, as you would with any other patient.

D. Check with his primary nurse to make sure his symptoms are adequately controlled.

Case Study 10: Mrs. Rubin is a 72-year-old Veteran who was given cardiopulmonary resuscitation (CPR) after a cardiac arrest. In the six months since, she never regained consciousness and is now in a persistent vegetative state (PVS). Mrs. Rubin has an advance directive that states she would not want any life-sustaining treatment, including a feeding tube, if she were ever in PVS. Her advance directive also names her husband as her health care agent. As the physician caring for Mrs. Rubin, you want to honor her advance directive and discontinue life-sustaining treatment, but Mr. Rubin is not willing to withdraw the feeding tube despite several family meetings.

What should you do?

A. Withdraw the feeding tube on the basis of the advance directive despite Mr. Rubin's objections.

B. Continue to give Mrs. Rubin artificial nutrition and hydration through the feeding tube.

C. Seek an ethics consultation.

D. Seek a court order to withdraw treatment.