The Rheumatologist
COVID-19 News
  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed
  • Home
  • Conditions
    • Rheumatoid Arthritis
    • SLE (Lupus)
    • Crystal Arthritis
      • Gout Resource Center
    • Spondyloarthritis
    • Osteoarthritis
    • Soft Tissue Pain
    • Scleroderma
    • Vasculitis
    • Systemic Inflammatory Syndromes
    • Guidelines
  • Resource Centers
    • Ankylosing Spondylitis Resource Center
    • Gout Resource Center
    • Rheumatoid Arthritis Resource Center
    • Systemic Lupus Erythematosus Resource Center
  • Drug Updates
    • Biologics & Biosimilars
    • DMARDs & Immunosuppressives
    • Topical Drugs
    • Analgesics
    • Safety
    • Pharma Co. News
  • Professional Topics
    • Ethics
    • Legal
    • Legislation & Advocacy
    • Career Development
      • Certification
      • Education & Training
    • Awards
    • Profiles
    • President’s Perspective
    • Rheuminations
  • Practice Management
    • Billing/Coding
    • Quality Assurance/Improvement
    • Workforce
    • Facility
    • Patient Perspective
    • Electronic Health Records
    • Apps
    • Information Technology
    • From the College
    • Multimedia
      • Audio
      • Video
  • Resources
    • Issue Archives
    • ACR Convergence
      • Systemic Lupus Erythematosus Resource Center
      • Rheumatoid Arthritis Resource Center
      • Gout Resource Center
      • Abstracts
      • Meeting Reports
      • ACR Convergence Home
    • American College of Rheumatology
    • ACR ExamRheum
    • Research Reviews
    • ACR Journals
      • Arthritis & Rheumatology
      • Arthritis Care & Research
      • ACR Open Rheumatology
    • Rheumatology Image Library
    • Treatment Guidelines
    • Rheumatology Research Foundation
    • Events
  • About Us
    • Mission/Vision
    • Meet the Authors
    • Meet the Editors
    • Contribute to The Rheumatologist
    • Subscription
    • Contact
  • Advertise
  • Search
You are here: Home / Articles / Ethics Forum: The Ethical Side of End-of-Life Decisions

Ethics Forum: The Ethical Side of End-of-Life Decisions

September 5, 2012 • By C. Ronald MacKenzie, MD

  • Tweet
  • Email
Print-Friendly Version / Save PDF

The Case*

A 22-year-old female with diffuse systemic sclerosis had presented to a major medical center four years earlier. Over the preceding years, she had experienced Raynaud’s phenomenon, puffiness of the hands, followed by diffuse skin thickening (hands, arms, face, neck, back, legs, and skin score of 19), as well as digital ulceration, calcinosis, and gastroesophageal reflux. The antinuclear antibody was positive at >1:2560 (nucleolar pattern), the anti-Scl70 antibody was negative. An echocardiogram revealed an elevated systolic pulmonary artery pressure (65 mmHg); pulmonary arterial hypertension (PAH) was confirmed by right heart catheterization. Managed with a combination of diuretics, endothelin receptor antagonists, phosphodiesterase 5 inhibitors, and prostacyclins, her clinical course was subsequently stable.

You Might Also Like
  • Ethics in Patients’ End-of-Life Care Compound Therapeutic Challenges for Rheumatologists
  • Ethics Forum: The Ethical Pitfalls of Clinical Trials
  • Ethics Forum: The Ethical Challenges of Recruiting Patients for Clinical Trials
Explore This Issue
September 2012
Also By This Author
  • Practicing Mindfulness Can Help Alter Patients’ Experience with Chronic Rheumatic Diseases

Following a period of poor adherence to therapy, her clinical status deteriorated precipitously with palpitations, syncope, and right heart failure. Admitted to the intensive care unit (ICU), an elevated troponin and severe right ventricular dysfunction raised the possibility of myocarditis. A myocardial biopsy revealed an interstitial lymphocytic infiltrate and intravenous cyclophosphamide was administered. Despite treatment, the patient’s clinical status deteriorated. Multiple aggressive interventions were employed in an attempt to bridge her to heart/lung transplantation. Despite mechanical ventilation, the implantation of a right ventricular assist device, and extracorporeal membrane oxygenation, further complications ensued including atrial arrhythmias, upper gastrointestinal bleeding requiring multiple blood transfusions, pneumonia, septic and cardiogenic shock necessitating vasopressor and inotropic support, renal failure with continuous hemofiltration, and ischemia of her right lower extremity.

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

Given the clinical circumstances and grave prognosis, a palliative care consultation was suggested but declined by the patient’s family, resulting in tensions between the family and the ICU staff. After five weeks of ICU based care, ventricular fibrillation developed and cardiopulmonary resuscitation was unsuccessful.

The Questions

This case raises a number of questions concerning the role of the consulting physicians in the ICU, the concept of medical futility, and the management of complex patients when the goals of care may be changing. Here are a few of the ethical considerations.

ad goes here:advert-2
ADVERTISEMENT
SCROLL TO CONTINUE
  1. What is the role of the rheumatologist in providing prognostic estimates in this case? Is such information likely to have altered the clinical decision making?
  2. What is meant by the term “futility” and how would it be interpreted in the case presented above?
  3. Who is best positioned to resolve the tensions that have arisen between the patient’s family and the ICU staff?
  4. An ethics or palliative care consultation could be requested. What expert is it most appropriate to call in these circumstances?

How would you address these ethical questions? Have you ever been involved in a similar case and, if so, how did you handle the ethical challenges involved? Additional comments are welcome. Please send your responses to dantoline@wiley.com. A summary of the responses will accompany an ethical analysis of the case in the December issue.

Pages: 1 2 | Single Page

Filed Under: Career Development, Education & Training, Ethics, Professional Topics Tagged With: end-of-life, ethical, Ethics, patient care, rheumatologist, Systemic sclerosisIssue: September 2012

You Might Also Like:
  • Ethics in Patients’ End-of-Life Care Compound Therapeutic Challenges for Rheumatologists
  • Ethics Forum: The Ethical Pitfalls of Clinical Trials
  • Ethics Forum: The Ethical Challenges of Recruiting Patients for Clinical Trials
  • Ethics Forum: Prescribing Teratogenic Medications to Adolescents Can Raise Confidentiality, Ethical Concerns

Rheumatology Research Foundation

The Foundation is the largest private funding source for rheumatology research and training in the U.S.

Learn more »

American College of Rheumatology

Visit the official website for the American College of Rheumatology.

Visit the ACR »

Meeting Abstracts

Browse and search abstracts from the ACR Convergence and ACR/ARP Annual Meetings going back to 2012.

Visit the Abstracts site »

The Rheumatologist newsmagazine reports on issues and trends in the management and treatment of rheumatic diseases. The Rheumatologist reaches 11,500 rheumatologists, internists, orthopedic surgeons, nurse practitioners, physician assistants, nurses, and other healthcare professionals who practice, research, or teach in the field of rheumatology.

About Us / Contact Us / Advertise / Privacy Policy / Terms of Use

  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed

Copyright © 2006–2021 American College of Rheumatology. All rights reserved.

ISSN 1931-3268 (print)
ISSN 1931-3209 (online)

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.
This site uses cookies: Find out more.