Ms. Smith is an 85-year-old woman with end-stage cardiac disease in a home hospice program. She has been very comfortable, not experiencing any other symptoms, and has been quite functional until the last two weeks. Her family contacts the home hospice nurse concerning her lack of appetite, “continual sadness,” and anxiety which they feel is affecting her ability to function.
During a routine home visit by the hospice nurse, the patient relates she has no appetite and is quite comfortable just having occasional “snacks” when she pleases. However, her family remains adamant that she requires better nutrition, and they request an IV be inserted. In addition, the family believes Ms. Smith is depressed and “too antsy,” and these contribute to her lack of appetite. Mrs. Smith states that she has had trouble with depression for many years, but has always tried to find “the brighter side” to fight off the sadness. She also acknowledges that she becomes anxious when her children come to visit, as they “don’t want to admit I am dying,” she says. She reports that she does not always sleep well at night, because she is afraid to die and leave her family behind. She says, “I wish I had raised my children better. If I had, there might not be all of this fighting going on about my care. I wish they would leave me alone, so I can die the way I want to.”
Discussion Questions:
- How might the hospice nurse incorporate interdisciplinary care for this patient?
- What additional assessments would be needed?
- What interventions might be considered?
Case Study
Perhaps the one case study that best depicts the effect that therapeutic jurisprudence might have involves the case of Theresa (Terri) M. Schiavo. Ms. Schiavo suffered a cardiac arrest in February 1990. She was without oxygen for approximately 11 minutes, or 5 to 7 minutes longer than most medical experts believe is possible to sustain without suffering brain damage. At the insistence of her husband, she was intubated, placed on a ventilator, and eventually extubated and received a tracheotomy. The cause of her cardiac arrest was later determined to be a severe electrolyte imbalance caused by an eating disorder, as Ms. Schiavo had lost approximately 140 pounds, going from 250 to 110 pounds, in the months before her cardiac arrest.
Ms. Schiavo was in a coma for the first 2 months after her cardiac arrest. She then regained some wakefulness and was eventually diagnosed as being in a persistent vegetative state (PVS). She was successfully weaned from reflexive behaviors. Characteristic of persistent vegetative state, Ms. Schiavo was not able to eat food or drink liquids, and a permanent feeding tube was placed so that she could receive nutrition and hydration.
Once the media became aware of Ms. Schiavo’s condition, court battles regarding the removal or retention of her feeding tube were initiated. During these hearings and trials, sufficient medical and legal evidence to show that Ms. Schiavo had been correctly diagnosed and that she would not have wanted to be kept alive by artificial means was introduced. Laws in the state of Florida, where Ms. Schiavo resided, allowed the removal of tubal nutrition and hydration in patients with PVS. The feeding tube was removed, but was later reinstated following a court order.
Questions:
- What legal issues concerning the scenario do you see?
- Do you see how the families’ desires conflict with Terry’s intended wishes? Identify the legal issues involved with this situation and then instruct a group of nurses about advanced directives and the lessons learned from Terry Schiavo.
- Finally, if you could make a law and put it into the Florida Legislation, what kind of law would you write that gives tribute to the suffering that Terry went through? Let’s call it Terry’s law in respect for her…