This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.
There is no hope that Rita will ever recover from her state and be restored to any cognitive functioning. She is completely dependent on others for care. Her body is stiff and so severely contracted that her fingernails cut into her wrists. Her face is red, puffy and swollen, and she drools on herself. She is missing teeth. Her bathing, oral care and personal hygiene are cared for by others. She must be turned every few hours to prevent bedsores.
A gastrostomy tube was surgically implanted in Rita's stomach 4 weeks after being admitted to hospital. It is the sole means by which Rita has received fluids and nutrition since then. Rita was 25 years old on the day of her accident and she is 31 years old today.
Rita's husband, Steven Hewitt, is waiting to talk to you about removing the feeding tube and allowing her to die.
CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^
YES NO The Candidate:
1. asks why husband wants to have feeding
tube removed or why he is raising this
issue now.
----|-----------------------------------------------------------
2. asks whether patient had made advance
directive or living will.
----|-----------------------------------------------------------
3. ascertains whether husband is the
appropriate decision maker. (e.g. "How
long were you married before the
accident?". "Do you feel you are well
informed about her wishes?", and/or "Do
you have legal power of attorney for
her?")
----|-----------------------------------------------------------
4. asks about other decision makers or if
husband is willing to have a family
meeting.
----|-----------------------------------------------------------
5. asks about discussions regarding
previously expressed wishes of the
incompetent patient.
----|-----------------------------------------------------------
6. ascertains whether other family members
or friends of the patient can provide
information about the patient's
previously expressed wishes.
----|-----------------------------------------------------------
7. ascertains whether husband's decision is
the one that Rita would make if she were
able to choose (i.e. is this what Rita
would want).
----|-----------------------------------------------------------
8. states that husband's request will be
supported and agrees to remove the
feeding tube or states that request will
be pursued with ethics committee or
knowledgeable authority.
----|-----------------------------------------------------------
9. asks whether patient was a religious
person or whether husband would like
support or counselling (e.g. from member
of clergy or psychiatrist).
----|-----------------------------------------------------------
10. describes what other care will be given
when tube is removed (e.g. mouth will be
kept moist, patient will not be
neglected).
=================================================================
RATE FROM 1-5:
+------------------------------------------------------------+
| | | | VERY | |
| POOR | FAIR | GOOD | GOOD | EXCELLENT |
| 1 | 2 | 3 | 4 | 5 |
+------------------------------------------------------------+
1. How would you rate the candidate's communication skills?
1 2 3 4 5
2. How would you rate the candidate's ability to address the
ethical issue in this case?
1 2 3 4 5
Your wife Rita was involved in a serious car accident 6 years ago. As a result of the accident she had a prolonged cardiac arrest. She is now lying in the hospital in a persistent vegetative state (PVS). PVS is a type of permanent unconsciousness or coma in which all cognitive functioning is gone but in which the brain stem continues to function to some degree. Rita breathes on her own and has periods of wakefulness (with her eyes open) and reflexive sleep/wake cycles, but she is unaware of herself or her environment. Her eyes, when open, move randomly in all directions, but they do not track objects or persons or respond to the environment around her.
There is no hope that Rita will ever recover from her state and be restored to any cognitive functioning. She is completely dependent on others for care. Her body is stiff and so severely contracted that her fingernails cut into her wrists. Her face is red, puffy and swollen, and she drools on herself. She is missing teeth. Her bathing, oral care and personal hygiene are cared for by others. She must be turned every few hours to prevent bedsores.
A feeding tube was surgically implanted in Rita's stomach 4 weeks after being admitted to hospital. It is the sole means by which Rita has received fluids and nutrition since then. Rita was 25 years old on the day of her accident and she is 31 years old now.
Before the accident Rita was an independent, healthy and active woman. She was studying to become a social worker.
She derived a lot of pleasure from physical activities such as biking, hiking and sports like tennis. It was hard to keep her still. During the first year of your marriage, Rita sprained her ankle and doctors advised her to stay off her feet. She was told to refrain from exercise for about a week. Rita was up and around after a few hours. She could not cope with the thought of being inactive and dependent.
Never in a million years did you expect such a tragedy to happen. Consequently you did not have conversations about what to do if this kind of thing happened. However, her lifestyle and other statements to family and friends suggest that she would not wish to continue her present existence without hope as it is. A former roommate recounted a conversation in which Rita indicated "if sick or injured she would not want to continue her life unless she could live 'halfway normal'". (This statement was made while discussing someone in a TV show who had been paralyzed after an accident.)
You have hoped and prayed for a miracle - some chance of Rita's recovery. For a long time you have known there is *NO* hope of recovery. You've watched her eyes open and hoped for some hint of recognition - but there has been none. You look at Rita lying in the hospital bed and see only the "husk" or "shell" of the woman you married. Her "spirit" is gone.
Your attitude is sincere and your manner is subdued. You are not overly upset and you do not cry. (After all, it has been 6 years.) You did not make this decision lightly. You have spoken to Rita's parents and her brother and they are in agreement with your request. You are not expecting to meet with resistance.
As her husband you say things like:
"I think what's happening to Rita is inhumane."
"I wouldn't want to live that way."
"She has a right to die with dignity."
"I know damn well if it were me I would be furious about
being kept alive and I feel very much that Rita would feel
the same way, because Rita cared very much for her family."
Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.
PROMPT 1 (immediately):
I'd like to talk to you about my wife, Rita. I'd like to
talk to you about removing the feeding tube.
PROMPT 2 (by 3-4 minutes):
I think she has a right to die with dignity. What she's
going through seems inhumane.
PROMPT 3(by 5-6 minutes):
Will you remove the tube?
PROMPT 4 (by 7-8 minutes):
What's going to happen?