Hypothetical end of life dilemma

Suppose there was a patient, Mr. B., with adenocarcinoma, a fast growing malignancy that begins in the liver, the pancreas, or another intestinal organ. Although the patient has lived twice the predicted 3 month life expectancy, the cancer has finally spread throughout the body - to the liver, the lungs, the intestines, and, now, the brain.

Mr. B. is a 50 year old engineer, divorced and has no children. When he found out about his cancer, he spent some time "getting his affairs in order." This month, he moved back to the town he grew up in, to live with his older sister, Mrs. S. Unfortunately, he has not seen a doctor in town, since he had planned to continue seeing the oncologist 50 miles away. The day after he arrived, Mrs. S. found him passed out on the floor of his room and called the ambulance.

On admission to the Emergency Room, Mr. B. is not conscious, can't swallow, and his liver and colon are not functional. The CT scan of the head shows a small mass, but the doctors explain that the problem is probably the loss of liver and kidney function.

The liver has completely shut down, causing the loss of the blood plasma protein normally made by the liver. The fluid from his blood moves from the veins and arteries into the body tissues by osmosis. The liver can't clean toxins from the body, so he is yellow, his blood vessels are losing the ability to hold blood pressure, and his kidneys are shutting down.

Mrs. S. refuses to hear of transferring Mr. B. to the big hospital 50 miles away where his oncologist practices. She insists that Mr. B. is a fighter and has already fooled the doctors by living so much longer than they predicted, and demands that he be given "everything possible" to prolong his life.

The family doctor who is assigned as Mr. B's new Dr. by the ER "on call list" has asked both of the kidney specialist groups in town to evaluate the patient for dialysis and each has separately advised him that the dialysis is not appropriate and declined the consult. For one thing, the veins in his arms and legs are not big enough to handle the amount of fluids necessary for dialysis, and he would need a surgical procedure to place a larger central IV line than the one that was placed in the ER.

The sister, Mrs. S, who is acting as the patient's surrogate for making medical decisions, is furious with the new doctor. Although by th day after admission, Mr. B.'s legs are swollen to the point that the skin has begun cracking and draining, she is certain that the patient is thirsty and hungry. Convinced that the doctor is "killing" and "starving" her brother, she calls a lawyer who takes the family doctor to court. The judge grants an emergency hearing and then orders the doctor to begin dialysis and provide adequate artificial nutrition and hydration.

The family doctor, who is board certified in Family Medicine, which requires continuing medical education and repeat certification each 7 years - in fact, he just passed his boards for the 3rd time - has never written the orders for dialysis, hasn't written orders for "total parenteral nutrition" (TPN) since he was in medical school, and hasn't placed a central line since residency 21 years ago. Besides, his hospital privileges don't include supervising dialysis. He's already explained all of this to the judge.

The doc, just looks at the judge and says, "Tell me, your honor, will you assist me in placing the central line and then dictate the exact orders you want me to write? What rate of filtration and how much pressure should I use in the dialysis? How much fluid can I safely remove, and how fast?"