We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place. Please send any cases that you would like considered for inclusion to: info@plainviews.org

We hope that this new addition will help to inform not only those who are dealing with the issue, but will enable all of our readers to learn from the experiences and perhaps mistakes of others.

PLEASE NOTE: Due to unanticipated continuing responses to both the case and the resolution of the case, added responses can be viewed in the archives. Click HERE.

Case Conference #3 (Responses are posted below the case)

A patient had won the lottery and her children had become more interested in her money than in a relationship with their mother. The patient had changed her will, excluding her children. Several months later, the patient suffered a massive stroke. She was connected to life support – intubated and receiving artificial nutrition and hydration. Her heart was starting to fail and the doctors approached the children about signing a Do Not Resuscitate Order because they felt it would not be in the patient's best interest to call a code and try to resuscitate her. The children refused to sign the DNR, hoping that they could get a court order and have their mother declared “incompetent” so that they could challenge the will. They also threatened to sue the hospital if the hospital staff did not do everything to keep the patient alive.

After several weeks and the physical deterioration of the patient’s body to a level that the staff considered to be “inhumane,” the staff asked the chaplain to talk with the children to see if the chaplain could convince the children to sign the DNR.

Should the chaplain intercede? If so, on what grounds?
If the chaplain intercedes, what should the “goal” of that intercession be?
Is this an appropriate use of the chaplain?

Responses to CaseConference #3

In my facility, it would be very appropriate for me to be involved. I'm the staff liaison to the ethics committee, so it would probably pass through me on the way to the committee.

Even before the committee meets, I would meet with the family and try to mediate a resolution. I have found that such cases might involve conflicts among the children; my presence could allow them to resolve those conflicts and start to look at the best interests of their mother. An unspoken issue would be that the ethics committee could intervene if, in the opinion of our doctors and lawyers, we were not acting in the patient's best interest.

Summary:
It would be appropriate for the chaplain to intervene, but with the goal of mediating a resolution. The use of our authority could be instrumental in allowing the family members to do what is right.

Rabbi Jim Michaels
Hebrew Home of Greater Washington
Rockville, MD

Should the chaplain intercede? This is exactly a case for a chaplain to step forward as an ethicist, and then as theologian. In my institution the DNR is a physician decision that is discussed with the family. If so, on what grounds? The ethics issue, for me, is the physician asking the family to sign a DNR. Asking the family to make a medical decision is problematic. If the chaplain intercedes, what should the “goal” of that intercession be? I work with medical staff, to help foster the three poles of the ethical discussion.

Is this an appropriate use of the chaplain? The chaplain has the ability to walk on both sides of the line between institution and patient/family. Who else is better equipped than the chaplain to care for the staff as they face triangulation between family, care for the patient, and the institution.

The family becomes my tertiary customer, and as such receives necessary energy for listening and reflecting. I have no need to teach, preach, or cajole this family into compassion. I may at some point plant a seed that indicates that the will may be easier challenge than guardianship.

Roy Sanders
Director Spiritual Care/Clinical Pastoral Education
Truman Medical Center Hospital Hill
Kansas City, MO

It is hard to imagine a scenario where the chaplain had not already been involved with the patient and her family as well as her visitors during the preceding weeks. In situations like this, the patient may have been transferred to an ICU from a neurological floor at the time of her intubation. As a result, the chaplain's assigned to the floor and the particular ICU ought to be more cognizant and conversant with each other about the minute details of her condition and wishes than the scenario suggests. It is also possible that one or the other chaplain's had heard the patient or others verbalize her wishes before her condition deteriorated.

Therefore, absolutely, "Yes" the chaplain ought to intercede because, as stated, the chaplain ought to have established a pastoral relationship with the children and may also have first-hand knowledge of the patients wishes. Accordingly, that information ought to have been clarified and documented in the patient's "Progress Notes" or anther appropriate chart entry. This information might also include the patients clarification about whether she stated her medical care wishes in legal language upon the advice of a competent attorney at the time her will was drafted.

As a result, the chaplain's intercession ought to be a part of a continuing conversation with the staff, including physicians, as is the case in many ICU's, to apprise them of the facts already recorded in the patient's chart; and to reiterate to the family that their mother's wishes were stated and as such must be honored. The big "If" is "if" what I have suggested is what occurred. If it isn't then the chaplain's goal of intercession is to first understand the physician's frustration or previous efforts to obtain consent from the children and then to build a relationship with the children before attempting to convince them that it is their mother's wishes that count, not theirs!

Deacon Mike Steele, Ph.D.
St. John’s Hospital
Springfield, MO

I believe the question is wrong. Making a patient DNR does not mean they will die when the ink dries. DNR just means that if the patient’s heart stops you do not attempt to resuscitate them. As I read this case the patient would still be alive when the staff asked the chaplain to talk to the family, because if her heart had stopped before that, resuscitation would not have worked anyway. The question is wrong because you are linking DNR with death. A clearer question would be About Using medical interventions. How much medical technology do you want us to use? There are a lot of family issues and to link that with DNR is a mistake.

Gordon Putnam, M.Div.
Chaplain/Support Services Coordinator
University of Virginia Cancer Center

With due respect for the above posted positions, I do not see this as a situation best addressed by the chaplain. True, chaplaincy could help sort out family dynamics, but this case seems to me to be one of legal standings. Too bad the patient hadn't prepared an advanced directive!

Here in Delaware, when the patient is too sick to make medical decisions, a condition distinct from being incompetent, the power to make those decisions is defaulted along a prescribed chain of persons, the first being a spouse, then children, etc. Since no spouse appears in the study, the responsibility would fall to the children. But the act of changing her will suggests, perhaps even demonstrates, that the relationship between the patient and her children is conflicted and raises credibility issues about their willingness to best serve the patient's needs and the patient's desire to have them fulfill the role.

Solving this dilemma involves no spiritual or religious questions. It isn't really even about the emotional support system, which until the patient could regain sufficient health to participate in the problem's solution, is beyond repair. It is about establishing the identity of a trustworthy guardian and ensuring that the patient receives the most responsible level of care, and it is about getting the hospital de-triangulated from this nasty family feud.

This is a job for the hospital's patient advocate. At most, the chaplain could facilitate a meeting with the advocate, the patient's attorney, and other interested parties and/or offer to pray for Divine guidance if not an intervention.

Peace,
Keith Goheen, MDiv
Chaplain
Beebe Medical Center
Lewes, DE

Please check below for comments made about the last CaseConference.

Send your comments about CaseConference to info@PlainViews.org.