In lieu of an abstract, here is a brief excerpt of the content:

133 7 Mediation with a Competent Patient: Mr. Samuels’s Case Background Mr. Samuels was a seventy-seven-year-old man admitted to the medical center from home with end-stage emphysema. According to Dr. Peterman, a pulmonologist who had been his community doctor for several years, Mr. Samuels was a “Damon Runyonesque character”—an irascible man who had never married, loved to gamble, and continued to smoke even after his health was threatened. Dr. Peterman treated him for emphysema for many years, although the patient, despite a worsening condition, refused to stop smoking, use his oxygen, or take his medications regularly. One year before the mediation of his case, Mr. Samuels was hospitalized in acute respiratory failure. He had had trouble breathing, he had widely disseminated infection in his blood (sepsis), and he had recently exhibited severe liver damage. At that time he was put on a ventilator. With treatment, he improved and was successfully weaned from the ventilator, but after he returned home, he deteriorated rapidly. At about this time, his companion of forty years, Dorothy Langer, gave up her apartment and moved in with him. She referred to herself as his common-law wife. Once a very active woman, she now suffered with severe arthritis and was compelled to use a walker. A few months later, Mr. Samuels complained of pain in his side and back, which Dr. Peterman initially thought was due to fractured ribs caused by several falls. Eventually Mr. Samuels was admitted to the hospital with severe back pain; an MRI showed possible metastases and a CT scan showed extensive osteoporosis . He was managed with medications, and although a bone biopsy was recommended , it was not done. The test requires that a patient lie on his stomach, which Mr. Samuels was unable to do because of his pulmonary compromise. He was put on a ventilator and there was a discussion about the possibility that he might not come off. Mr. Samuels was very clear that he did not want to live like that. Finally, however, a biopsy showed no cancer and he was again weaned from the ventilator. At that time, Mr. Samuels appointed Ms. Langer as his health care proxy. 134 Bioethics Mediation: A Guide to Shaping Shared Solutions Subsequently, Mr. Samuels experienced more respiratory problems that led to a readmission to the pulmonary intensive care unit (PICU). He suffered a cardiac arrest and was put back on the ventilator, from which it was not possible to wean him. Mr. Samuels, however, began asking to be extubated or removed from the ventilator , clearly articulating his understanding that removal might very well lead to his death. Ten days after the intubation, a tracheostomy was recommended to make him more comfortable and perhaps permit him to speak. Mr. Samuels initially refused and again asked to be allowed to die; this was on a Friday. Dr. Peterman was concerned about proceeding without Ms. Langer and suggested waiting until Monday when he would again be on duty. During the weekend, Ms. Langer came in with her nephew, a doctor at another metropolitan hospital, and together they persuaded Mr. Samuels to consent to the procedure. Throughout this period, there had been numerous discussions with Dr. Peterman and other caregivers about the consequences of extubation, and Mr. Samuels had been consistent and clear about his wish to die. At one point, Dr. Peterman wrote on a piece of paper, “You want to die” and “You want to live.” The patient signed his name under the first sentence. Ms. Langer was vehemently opposed to extubation and insisted that Mr. Samuels did not know what he wanted. She was far from certain that he wanted to die. She believed that he was simply depressed. At this point Dr. Peterman asked for a bioethics mediation. The first step the mediator took, after meeting with the care team, was to ask for a consultation with a psychiatrist from Geriatric Psychiatry. Dr. Garrison conducted a psychiatric evaluation and found Mr. Samuels to be capacitated and appropriately depressed about his situation. In her opinion, it would be unethical to give him psychotropic medicine to combat depression for the sole purpose of changing his mind about extubation. The risk manager, Ms. Torrent, supported the hospital’s honoring the patient’s request. The mediator met with Dr. Peterman and several members of the care team, after which she and Dr. Peterman met for an extended discussion with Ms. Langer. Ms. Langer was quite desperate and had not...

Share