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.

Responses to CaseConference #10

What is the chaplain's pastoral role with the patient? The wife? The other family? The staff? Advocating for the family for the time they need, letting the staff or administration worry about hospital cost. They need time for closure, grief, coming to terms with his state. They also need their own religious resources, such as a rabbi, to be a part of the team. The time spent with family and keeping one’s mind open to family system issues may give some hints of what is needed for closure. You really want to look down the shotgun barrel with them at what is troubling rather than stand in front of it in ANY adversarial way.

What are the ethical issues in this case? Keeping someone alive in PVS.

What is the chaplain's role in helping to resolve these ethical issues with the wife? The other family? The staff? The wife and/or family may be open to prayer. They may be willing to discuss history of similar events in their lives, for example, with a parent who has died and what that is like. Helping the family hear the medical staff would probably be the best thing you could do for the staff. Helping staff see the need to support their hope to some extent so that trust was rebuilt. Otherwise, it is an untenable situation and is fraught with litigation possibilities

Alan Williams, BCC, ACPE
Pastor
Calvary Lutheran Church
San Angelo, TX

This case involves two cultural issues:

1. The reluctance to disconnect life-support reflects a Jewish urge to preserve life at all costs. Although many rabbis of all denominations have indicated support for disconnecting such systems if a patient is brain-dead, the issue of a permanent vegetative state is not as clear. Moreover, even if the family is not religious, the wife may be ambivalent about saying goodbye. I have often found such ambiguity among Jews, even those whose loved ones have given advance directives about their care.

2. The emotional response of the patient's wife is typical of European Jewish immigrants. If the woman's primary language is still Russian or Yiddish, this may be her way of expressing her grief. As presented, I don't think she is a suicide risk. There may be unresolved issues which she needs to address before she can say good-bye to her husband.

The chaplain's role is two-fold: First, honor the wife's feelings. Second, over time explain the futility of keeping the patient on life-support. It may be helpful to consult with the family's rabbi, and to ask for his/her intervention. Over time, the family will determine what's in the patient's best interests, and what is in theirs. This might include moving the patient to a skilled nursing facility or removal of life-support. In addition, the chaplain should explain the cultural and religious issues to the staff so they can respect them.

Finally, if the wife is receptive to the ministry of presence, the chaplain should continue to play that roll. It may eventually provide an opening for her to talk about her feelings in this difficult situation.

Rabbi Jim Michaels
Director of Pastoral Care
Ethics Committee staff liaison
Hebrew Home of Greater Washington

Several things came to mind in the initial reading of this case:

-The importance of advanced directives.
-Education to the community, churches, and senior housing facilities about the importance of having “the conversation” with your loved one about your wishes.
The fact that shock and denial are key players in the wife’s grief and that seems to be where she is at the moment. It’s important to address those stages and acknowledge them.
-Would the patient want to live this way even if there was the remote possibility of limited recovery?
- Are there unresolved issues within the family that need to be addressed?
- Is the family at a loss as to how to “say goodbye” to a loved one?

Since I am a hospice chaplain, has the hospital facility utilized the local hospice to offer the family support and counsel, even if the patient is not admitted to hospice care?

Rev. Amy Jo Jones, BM, MM, MDiv., BCC
Chaplain/Grief Support Center Coordinator
Big Sky Hospice
Billings, MT

The role of the chaplain is quite frequently, if not always, to help meaning come forward. How I can see this unfolding in this particular case is to help the wife speak to what it means for her to experience her husband in this condition. What the present is like for her. Something as simple as "I don't know what it's like for you" may be the invitation to companionship that this woman needs. Likewise, the "miracle" piece seems to be dangling out there unaddressed. What would a miracle look like? What does a miracle mean to her.

On the ethical side is a huge issue of patient driven care. It seems like all decisions are being made on the basis of what the wife wants, while there is no place for the voice of the patient. Did he have any advanced directives? Were there any conversations between the spouses when he was otherwise healthy? What gave his life meaning? What are the chances of him recovering to a meaningful life experience? Based on the description the patient has suffered a pretty devastating anoxic brain injury which "killed" the husband that the wife knew-but does she know this, does she understand? Even if it weren't for the anoxic injury, he seems to have been close to futility anyway.

It doesnt seems like an effective course to try to convince the wife of anything. It seems like a more helpful frame, from the perspective of Spiritual Care as well as the rest of the Healthcare team would be to talk about meaning-both what it means for her to experience this and what gave his life meaning.

Andrew Schoenfield, M.Div.
Priest-Chaplain
Archdiocese of Seattle
Department of Spiritual Care, UW Medicine
Harborview Medical Center

CaseConference #10

Mr. M is a 65-year old male of Russian Jewish ancestry who immigrated to the US after the SEcond World War. End-stage renal disease placed him on dialysis. Recently he made the decision to go on the kidney transplant list. In early March 2006 he suffered chest pains. A cardiac cauterization was scheduled. The results of this procedure showed cardiac by-pass surgery was necessary. The following day a quadruple cardiac by-pass was performed.

Mr. M survived surgery, however he had great difficulty being removed form the ventilator. Once weaned from the ventilator he had a cardiac arrest. He was anoxic for a prolonged period of time.

Multiple complications followed the arrest: various infections, septic wounds, and decubetus, repeated replacement of central lines and feeding tubes and dialysis problems.

EEG’s have determined limited brain activity; but is not considered brain dead.

More accurately Mr. M can be described as existing in a permanent vegetative state - PVS. He remains a full code. He was recently transferred from the Coronary Acute Care Unit to an Advanced Ventilator Step Down Unit. His wife refuses to accept a Skilled Nursing Facility placement.

His wife and brother keep a vigil at his bedside during visiting hours believing he will come back to a fullness of health. They seek a miracle.

The family will not listen to the medical staff as they attempt to address the issue of withdrawal of life support.

The patient’s wife who is by training a dentist, calls to him at all times “wake up – come back – do not leave me.” She has repeatedly stated that she would kill herself if he should die, as she has “nothing.”

She refused to accept anything other than the ministry of presence. When Psychiatry sought to intervene, she physically ejected the doctor from the unit. She speaks only of her love for her husband. She feels the hospital is not treating him aggressively enough.

What is the chaplain's pastoral role with the patient? The wife? The other family? The staff?

What are the ethical issues in this case?

What is the chaplain's role in helping to resolve these ethical issues with the wife? The other family? The staff?

Please check the archives below for comments made about the last CaseConference.

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