Question:

Please Just Turn This Thing Off! 

A nursing assistant wheels Margie Whitson back to her room at Golden Oaks Rehabilitation Center and helps her back into bed. Golden Oaks is located on the grounds of Marion General Hospital, owned and operated by the hospital board of directors.

It has been a very difficult day. Margie takes a deep sigh as she leans back into bed and says, "I'll get into night clothes in a few minutes if that's alright. I'd just like to sit here and think for a little while." The nursing assistant nods in agreement

Margie has just attended the funeral of her son William, who died this week after several years of poor life quality in the same nursing facility. William's first stroke happened 3 years prior; two more strokes followed, and he lingered in poor health at the center over the intervening time. Margie is now 95 years of age, and William was 73 when he passed this week.

The last 5 years have simply been devastating for Margie. First her husband Earl passed on at the age of 88. They had been married for 68 years, most of them wonderful and successful years together, until the medical problems began. They had one other son, Jacob, who died in a motor vehicle accident in his 30s.

As Margie sits in the quiet of her nursing home room, she faces the reality that she is utterly and completely alone in the world. She and Earl had hoped for grandchildren, but that never happened, and Margie's family is simply all gone now. Margie's own health is poor. A hip fracture 10 years ago slowed her down significantly, and a heart attack 2 years ago nearly took her life. But she survived due to good emergency medical care and quick placement of an electronic pacemaker. Margie's heart rhythm is now 100% paced, meaning that her heart will not function effectively without the pacemaker; she is completely dependent on the pacemaker for her survival.

Margie is a woman of great personal faith, raised that way, and she raised her sons that way. She believes strongly that Earl, William, and Jacob are waiting for her in heaven. And as she sits alone in her nursing home room, the realization comes to her-the only thing keeping her from joining her family in heaven is this pacemaker. And the pacemaker is nothing more than an electrical device. It was turned on to save her life 2 years ago, and now it can be turned off. She should have the right to turn it off! Margie presses the nurse call button and says, "I need to see that lady who's in charge of this place, and right now please."

When Nursing Home Administrator Cindy Mackin enters the room and listens to Margie, she can hardly believe what she is hearing. "I'm telling you I just want you to turn it off. I've had enough; there is nothing left for me here on earth and I just need to go now and be with my family." Cindy responds, "Now, Margie, you've had a terrible time lately, and naturally you are grieving the loss of your son right now. Things will look better tomorrow." But Margie does not think so. She says, "Call Dr. Vijay for me; he turned this thing on, and he can turn it off. I insist."

Cindy realizes that Margie does have a right to discuss this or any other matter with her doctor, and she arranges a visit for the following week. At the cardiology clinic, Margie is increasingly insistent about her demand to deactivate the pacemaker. Dr. Vijay comments, "Margie, I've practiced cardiology for nearly 20 years now, and frankly I have never had this request. The pacemaker is keeping you alive, and that is of course what we do in medicine-we save lives. I do not feel that I can ethically deactivate your pacemaker. I know that you have had some very difficult experiences lately, and perhaps you will feel differently with a little time passing."

Returning to Golden Oaks, Margie is absolutely fuming, and now she is determined. The same determination that carried her through life and made her such a great wife and mother is now rising in her to make her own decision about how and when to end her own life. She asks to see the Golden Oaks social worker, and Jane Robison, MSW, is summoned. After more than an hour of discussion and exploration of every option that Jane can imagine, Margie persists in her request. "Well, Margie, we do actually have a process to help in difficult situations like this, when patients, families, and doctors disagree, through the hospital ethics committee, and I think that We should take your case there for review. I happen to know that the ethics committee meets next Friday, and the chairman is a colleague of mine who is our director of social services."

Your Assignment

You are David Jamison, MHA, ethics committee chairman at Marion General Hospital. Coming before your committee today is the case of Margie Whitson, age 95, who wishes to have her pacemaker deactivated. Her physician, Dr. Rana Vijay, has declined to honor her request in this matter, citing ethical concerns with such an action. It will be your job to thoroughly analyze the issues in this case and to make a recommendation from the ethics committee.

Key Players

You Decide

Activity or Assignment

Prepare a two-three page paper analyzing the key issues in this case and stating a recommendation. Be sure to include the following steps in your analysis.

1. Identification Identify the dilemma. What morals are involved? What morals are in conflict?

2. Information Get as much information as possible about the dilemma. Often this step is taken too quickly, without enough solid and detailed information, leading to bad decisions.

3. Communication Talk with other healthcare professionals on the case. Do they agree that there is a dilemma? Do they concur with your understanding of the dilemma? Do you know everything that they know about the case, and vice-versa?

4. Choice When all the talking is done, a choice needs to be made about what to do regarding the dilemma. A choice must be made. Even choosing not to decide is a decision!

Your role here is to prepare a recommendation on behalf of the ethics committee, with input from all participants, considering the best