With no family and few friends, Almeda was an eighty-four-year-old woman who lived a semi-retired life in the country. She had a disabling stroke three years ago and has been confined to a nursing home bed ever since, according to her family.





Almeda has lost the ability to make decisions and has left no advance directives. Barbara’s longtime friend Barney has served as an unofficial substitute decision maker for the past several years. After developing stage IV sacral decubitus, which is now colonized with multiple resistant staphylococcus areus and pneumonia combined with heart failure, Almeda was referred to the hospital. She is currently undergoing treatment in the intensive care unit.





Alameda has been on a ventilator and receiving nutrition through a gastric feeding tube for the past two weeks. During this time, she has been treated with high-dose cardiovascular medications as well as the antibiotic Vancomycin. There has been no improvement in either the heart failure or the pneumonia situations. Almeda, despite her stoicism, shows obvious signs of discomfort when she is moved around for care. 


It has been brought up to Barney on numerous occasions by the nurses and attending physician, who have raised the issue of discontinuing aggressive curative treatment in favor of palliative care.

†Barney has always insisted that Almeda’s condition has more potential than is currently apparent. “It would be nice if she could be able to sit up and watch some television,” he said when asked what the appropriate goal for Almeda should be. ”

††Almeda’s renal function has now deteriorated to the point where his serum creatinine has risen to levels that necessitate his being placed on renal dialysis. Upon learning that Barney would be undergoing dialysis, the nursing staff requested a meeting with the attending physician and Barney to discuss the possibility of shifting treatment from curative to palliative care.

Questions to consider during the discussion
When discussing the ethical implications of the preceding case, use the following questions as a guide to ensure that you cover all of the bases.




Which stakeholder raises the question of treatment redirection makes a difference, according to the researchers. What would have happened if Barney had voiced his dissatisfaction with the treatment plan? Who is to blame: the nurses, doctors, or Almeda herself? 



â€Does the absence of advance directives make the treatment redirection process more difficult or more straightforward?



• If treatment redirection to palliative care is necessary, is Barney an appropriate substitute/surrogate decision maker to consent to the change? 



Does it make sense to take some sort of “official” or “legal” action in order to proceed with a treatment redirection process?





â€If Almeda were able to contribute to the discussion, what would she prefer to see happen?



• Is Barney’s description of Almeda’s ultimate goal sufficient to justify the continuation of aggressive curative treatment?



• If we look at the case text, do we see any evidence that the attending physician has been sufficiently proactive in trying to inform and persuade Barney that treatment redirection is necessary? 



In the event that Almeda was gradually improving, what should have been the nursing staff’s point of view? What if she wasn’t improving and wasn’t deteriorating either?



• What is it about the prospect of renal dialysis that causes the treatment-redirection process to be raised to the top of the priority list? Why wasn’t this done when the gastric tube was placed? In other words, when did the ventilator kick in?