Sample Case Analysis

Case:
John, a 32 year-old lawyer, had worried for several years about developing Huntington's chorea,
a neurological disorder that appears in a person's 30s or 40s, resulting in uncontrollable
twitching and contractions and progressive, irreversible dementia. It typically leads to
death in about 10 years.
John's mother died from this disease. Huntington's is autosomal dominant and children of an
affected person have a 50% chance of inheriting the condition. John had indicated to many
people that he would prefer to die rather than endure the progression of the illness. He was
anxious, drank heavily, and had intermittent depression, for which he saw a psychiatrist.
Nevertheless, he was a productive lawyer.
John first noticed facial twitching 3 months ago, and 2 neurologists independently confirmed a
diagnosis of Huntington's. He explained his situation to his psychiatrist and requested help
committing suicide. When the psychiatrist refused, John reassured him that he did not plan to
attempt suicide any time soon. But when he went home, he ingested all his antidepressant medicine
after pinning a note to his shirt to explain his actions and to refuse any medical assistance that
might be offered. His wife, who did not yet know about his diagnosis, found him unconscious and
rushed him to the emergency room without removing the note.
How much weight should Johns preferences (especially his attempt to end his life) carry in
managing his emergency and subsequent clinical care?
Review of Topics:
Medical Indications
There are 2 diagnoses/prognoses that merit consideration. The underlying chronic disease of
Huntington's is incurable and symptoms progress with a bleak long term prognosis. However, there
are effective treatments available for the acute diagnosis of drug overdose including gastric lavage
(pumping his stomach), emetics, antidotes, and/or activated charcoal (to prevent undigested drugs
from entering his blood stream); supportive treatment following the initial treatment; and
medications to ameliorate the underlying depression. How does the diagnosis of Huntington
Disease affect our response to the acute condition? We know that the standard of practice is to
assume that patients admitted for suicide attempts lack decisional capacity.
Patient Preferences
We know from the patient's suicide note that he is refusing all medical treatment. However, what do

we know about these statements of preference? Were they informed? Was the patient competent to
make that decision? The answers to these questions remain unclear, but we do know that the patient
does not have decision making capacity for the present decision of whether to proceed with the
gastric lavage. Is there a surrogate decision maker available?
Quality of Life
Life with Huntington's can be difficult. John was familiar with the quality of life associated
with living with Huntington's as he watched his mother die of this disease. On the other
hand, John does have a supportive family and continues to be able to work for the time
being. How should the diminished quality of life that is anticipated in the future affect
current clinical management?
Contextual Features
Several factors in the context of this case are significant. While the patient has a legal right
to refuse treatment, he is currently unconscious and his surrogate (his wife) is requesting
treatment. There are also certain emergency room obligations to treat emergent conditions.
How should the emergency staff weigh the various competing legal and regulatory duties?
Case Analysis:
John has indicated through his note that he refuses potentially life-sustaining treatment, but
his competency to make decisions is questionable in the context of attempted suicide. Also
at issue is the distinction between the acute and chronic conditions.
The precedent for cases such as this one is fairly clear. When the patient's preferences are
unclear or health care providers have reason to believe a patients decision-making
capacity is compromised; the acute condition is easily treatable; and the harm of not
treating is very great, emergency medical treatment of the immediate life-threatening
condition is provided, creating an opportunity to talk with the patient about his preferences
regarding his chronic condition at a later time and to treat any underlying depression that
may have contributed to his suicide attempt.
Notice that the facts of this particular case determine whether the precedent case is
applicable. If the medical team was familiar with this patient's expressed preference to
refuse any medical treatment and if the available treatment for the acute condition was
considerably less certain to be effective, the case could be decided differently. The
clinicians would look for a different precedent. .

A
case-based
approach
to
ethical
decision-making
Adapted from AR Jonsen, M Siegler, W Winslade, Clinical Ethics, 7th edition. McGrawHill, 2010
MEDICAL
The Principles of Beneficence and Nonmaleficence
1. What is the patients medical problem? Is the problem acute? Chronic? Critical?
Reversible? Emergent? Terminal?
2. What are the goals of treatment?
3. In what circumstances are medical treatments not indicated?
4. What are the probabilities of success of various treatment options?
5. In sum, how can this patient be benefited by medical and nursing care, and how can
harm be avoided?
1. Apa masalah medis pasien? Adalah masalah akut? Kronis? Kritis?Reversible?
Muncul? Terminal?
2. Apa tujuan pengobatan?
3. Dalam keadaan apa yang perawatan medistidak diindikasikan?
4. apa kemungkinan keberhasilan dari berbagai pilihan pengobatan?
5. Singkatnya, bagaimana bisa pasien ini diuntungkan oleh perawatan medis dan keperawatan,
dan bagaimana bahaya harus dihindari?
PATIENT
The Principle of Respect for Autonomy
1. Has the patient been informed of benefits and risks, understood this information, and
given consent?
2. Is the patient mentally capable and legally competent, and is there evidence of incapacity?

3. If mentally capable, what preferences about treatment is the patient stating?

4. If incapacitated, has the patient expressed prior preferences?
5. Who is the appropriate surrogate to make decisions for the incapacitated patient?
6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
Prinsip Menghargai Otonomi
1. Apakah pasien telah diberitahu tentang manfaat dan risiko, mengerti informasi ini,
dan memberikan persetujuan?
2. Apakah pasien mampu secara mental dan cakap melakukan perbuatan hukum, dan ada
bukti ketidakmampuan?
3. Jika mampu secara mental, apa pilihan tentang perawatan pasien ?
4. Jika tidak mampu, sudahkah pasien menyatakan preferensi sebelumnya?
5. Siapakah pengganti yang tepat untuk membuat keputusan untuk pasien tidak mampu?
6. Apakah pasien mau atau tidak mampu bekerja sama dengan pengobatan medis?
Jika demikian, mengapa?
QUALITYOFLIFE
The Principles of Beneficence, Nonmaleficence, and Respect for Autonomy
1. What are the prospects, with or without treatment, for a return to normal life, and what
physical, mental, and social deficits might the patient experience even if treatment succeeds?
2. On what grounds can anyone judge that some quality of life would be undesirable for
a patient who cannot make or express such a judgment?
3. Are there biases that might prejudice the providers evaluation of the patients
quality of life?
4. What ethical issues arise concerning improving or enhancing a patients quality
of life?
5. Do quality-of-life assessments raise any questions regarding changes in treatment

plans, such as forgoing life-sustaining treatment?

6. What are plans and rationale to forgo life-sustaining treatment?
7. What is the legal and ethical status of suicide?
Prinsip Beneficence, Nonmaleficence, dan Menghormati Otonomi
1. Bagaimana prospek, dengan atau tanpa pengobatan, untuk kembali ke kehidupan
normal, dan apa defisit fisik, mental, dan sosial yang mungkin pengalaman pasien bahkan
jika pengobatan berhasil?
2. Atas dasar apa bisa ada yang menilai bahwa beberapa kualitas hidup akan
diinginkan untuk seorang pasien yang tidak dapat membuat atau mengungkapkan
penilaian semacam itu?
3. Apakah ada bias yang mungkin merugikan evaluasi penyedia dari pasien kualitas hidup?
4. Apa masalah etika timbul mengenai membaik atau meningkatkan kualitas pasien hidup?
5. membuat pernyataan untuk melaukakan kualitas hidup penilaian meningkatkan
pertanyaan tentang perubahan rencana pengobatan,, seperti forgoing pengobatan
mempertahankan hidup?
6. Apa rencana dan dasar pemikiran untuk melupakan pengobatan mempertahankan hidup?
7. Bagaimana status hukum dan etika bunuh diri?
CONTEXTUAL
The Principles of Justice and Fairness
1. Are there professional, interprofessional, or business interests that might create
conflicts of interest in the clinical treatment of patients?
2. Are there parties other than clinicians and patients, such as family members, who
have an interest in clinical decisions?
3. What are the limits imposed on patient confidentiality by the legitimate interests
of third parties?
4. Are there financial factors that create conflicts of interest in clinical decisions?
5. Are there problems of allocation of scarce health resources that might affect

clinical decisions?
6. Are there religious issues that might affect clinical decisions?
7. What are the legal issues that might affect clinical decisions?
8. Are there considerations of clinical research and education that might affect
clinical decisions?
9. Are there issues of public health and safety that affect clinical decisions?
10. Are there conflicts of interest within institutions or organizations (e.g. hospitals)
that may affect clinical decisions and patient welfare?
Prinsip Keadilan dan Kejujuran
1. Apakah ada profesional, interprofessional, atau kepentingan bisnis yang mungkin membuat
konflik kepentingan dalam pengobatan klinis pasien?
2. Apakah ada pihak lain selain dokter dan pasien, seperti anggota keluarga, yang
memiliki kepentingan dalam keputusan klinis?
3. Apa yang batas-batas yang dikenakan pada kerahasiaan pasien dengan kepentingan sah
dari pihak ketiga?
4. Apakah ada faktor keuangan yang menciptakan konflik kepentingan dalam keputusan klinis?
5. Apakah ada masalah alokasi sumber daya kesehatan yang langka yang mungkin
Mempengaruhi keputusan klinis?
6. Apakah ada masalah keagamaan yang mungkin mempengaruhi keputusan klinis?
7. Apakah isu-isu hukum yang mungkin mempengaruhi keputusan klinis?
8. Apakah ada pertimbangan dari penelitian klinis dan pendidikan yang mungkin
mempengaruhi keputusan klinis?
9. Apakah ada masalah kesehatan dan keselamatan publik yang mempengaruhi
keputusan klinis?

10. Apakah ada konflik kepentingan dalam lembaga atau organisasi (rumah sakit mis)
yang dapat mempengaruhi keputusan klinis dan kesejahteraan pasien?