Case Studies in EndofLife Care

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Case Studies inEnd-of-Life Care

• Karen Ann Quinlan
• Rels 300 / Nurs 330
• October 2008

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Karens Story

• Karen Ann Quinlan
• 1954-1985
• Karen was a young woman whose name became
  symbolic of the legal and ethical dilemmas
  surrounding the treatment of terminally ill
  patients.

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Karens Story

• 15 April 1975
• Karen was at a friends birthday party
• she took a combination of benzodiazepine,
  alcohol, and barbiturates
• as a result, the blood supply to her brain was
  severely diminished (anoxia)
• she became unconscious
• she slipped into a coma
• doctors determined that her brain was
  irreversibly damaged and she would never recover

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Karens medical care

• Karen remained in hospital and in a coma
• her breathing was supported and regulated by a
  respirator
• she was artificially fed by a nasogastric feeding
  tube
• doctors continued to hold out no hope that she
  would ever recover

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Over Time

• Karen remained in a coma
• she became emaciated, losing more than 40 pounds
• she most often lay curled up in a fetal position
• her condition continued to deteriorate
• she had extreme flexion-rigidity of her arms,
  legs and related muscles
• her joints were severely rigid and deformed.

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Chronic and persistent "vegetative" state 1
month

• Karen had no awareness of anything or anyone
  around her
• she had some brain stem function that enabled
  primitive reflexes
• she moved reacted to light, sound and noxious
  stimuli blinked her eyes and grimaced made
  sounds and cries and had chewing motions
• her heart beat and her blood pressure was normal
• her appearance was similar to this

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What should be done?

• The attending physicians concluded that there was
  no reasonable possibility of Karen's ever
  emerging from her comatose condition to a
  cognitive, sapient state
• Karens parents agreed with this determination
• physicians and parents decided that the
  life-support apparatus being administered to
  Karen (respirator) should be discontinued

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Why did Karen live almost 10 more years?

• Some medical staff objected
• they interpreted brain stem activity as evidence
  of life
• knowing that the case was proceeding to court,
  caregivers gradually weaned Karen from her
  dependence on the respirator
• when the case for removing the respirator was
  granted, Karen was able to breathe unassisted
• with the support of artificial nutrition
  hydration, Karen lived in a nursing home until
  1985 (10 more years)
• her condition never improved

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Brain Function

• cortex (higher brain)
• has measureable brain waves (EEG)
• enables consciousness, feeling, emotion, memory
  thought
• brain stem (lower brain)
• enables spontaneous functions such as swallowing,
  yawning, sleep/wake cycles, respiration

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Coma

• a state of deep and prolonged unconsciousness
• thinking, feeling, memory are absent
• person is not reactive, i.e., does not see, hear,
  respond to pain, wake, or turn toward sounds or
  movements
• person does not respond to language, or other
  forms of personal communication
• coma may be temporary (days, weeks, months,
  years) and reversible, or permanent

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Persistent Vegetative State

• like coma
• cognitively unaware and unconscious
• respiratory, cardiovascular, renal function may
  be intact

• unlike coma
• sleep-wake cycles
• open shut eyes change facial expressions move
  limbs
• grind teeth, swallow, smile/grimace, shed tears,
  grunt/moan/scream
• but open eyes do not see facial movements and
  sounds are not expressions of emotions

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Criteria for Determining Death

• Cardio-pulmonary criteria
• irreversible cessation of circulation
• no pulse
• no heart beat
• resuscitation (if appropriate) has been attempted
• irreversible cessation of respiratory function
• person is not breathing spontaneously
• there is no obstruction
• the person is not hypothermic

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Other criteria

• Neurologic criteria
• irreversible cessation of all brain function
• reversible causes of brain dysfunction have been
  excluded
• drug intoxication
• treatable metabolic disorders
• hypothermia
• shock
• peripheral nerve or muscle dysfunction

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For the 10 years that Karen lay in a persistent
vegetative state, was she dead or alive?

• In what respects was she still alive?

• In what respects had her life ended?

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Design a treatment plan for Karen

• What will be part of her routine, day to day
  care?
• What further therapeutic interventions would you
  be ready to initiate if needed?
• What further therapeutic interventions would you
  regard as inappropriate?
• e.g. respirator CPR artificial nutrition
  antibiotics other medications physiotherapy ?

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Come to a consensus

• If you were various members of a treatment team
  for Karen, what care plan would you develop?
• What would be the basis on which these decisions
  were made? What human values are important?
• How will your care preserve the human dignity of
  Karen?
• How will you explain your treatment decisions to
  Karens family?

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Policy Implications

• Take this one step further. If you were an
  administrator of a hospital or nursing home, what
  institutional policies would the case of Karen
  Ann Quinlan suggest to you?
• How would you balance the benefit of preserving
  human life and dignity with the costs (personal,
  medical, financial, social) of maintaining such a
  life?