SOCIAL WORK THESIS GCYPHER

RUNNING HEAD: ADVANCED CANCER PATIENT’S WISHES AT END-OF-LIFE 1

Case Presentation:

Janice Keller is a 62-year-old white female who was diagnosed with Non-Hodgkin’s

Lymphoma in February of 2011. She and her husband had recently retired and were planning

their retirement together. She was in perfectly good health before she was ill. Janice’s battle with

cancer got increasingly worse over a four year period. She was receiving chemotherapy and

radiation treatments. In the last year of her illness, Janice began getting very sick and very

confused. Her husband took her to the Emergency Room many times for confusion and

dehydration.

The patient began her diagnosis stating she was determined to beat the cancer. The cancer

Center Social Worker met with the patient and her husband throughout her treatment. She denied

depression and stated she was motivated to complete treatment and “move on with life.” Janice’s

family was very supportive and her husband was able to attend all of her appointments. During

the final year of her life Janice stated that she was having “more bad days than good” (Hospital

Chart, 2015). She also stated that she was not coping with her diagnosis. The Cancer Center

Social Worker offered the couple counseling services, support groups, and in home services but

they declined help. Two months before Janice passed, her husband expressed his concerns. He

stated that his wife had “given up” (Hospital Chart, 2015). He shared that Janice had lost

functioning and independence but that he was hopeful Janice would “come out of this” (Hospital

Chart, 2015). Janice’s husband also shared his fears that she would not recover.

Janice’s nurses also noticed her declining happiness. One nurse’s note at the beginning of

the month that the patient passed stated that she was not doing well. The nurse wrote that

“patient appears withdrawn, no eye contact made, when asked how patient doing, no response,

head held low and started crying, patient husband stated ‘she’s given up, she doesn’t want to

ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 2

drink or eat or do anything anymore’ offered support, words of encouragement, no response from

patient” (Hospital Chart, 2015).

The patient’s statement of incapacity was signed and her medical power of attorney was

activated on October 21st. This means that her husband became her medical decision maker. This

was activated due to her persistent confusion. Although, Janice did experience periods of

coherence, she was not able to make her own medical conditions.

The patient’s condition was becoming much worse during the time her husband was

named the medical decision maker. Janice was physically sick and looked very discolored,

withdrawn, and frail. She had made many statements that she was done fighting and wanted to

stop treatment. Her husband was very visibly upset by these statements. Her husband wanted her

to continue treatment even thought this treatment was not curative. Meaning, for her condition,

any treatment would just prolong life and not cure the cancer. The patient had expressed wanting

to end treatment but her husband, who is her medical decision maker, wanted her to keep

fighting.

The medical team noticed this discrepancy between what the patient wanted and what the

medical decision maker was doing. The patient’s doctors and nurses conducted family care

meetings with the patient and her husband to make sure that he was making the best choices for

the well-being of the patient.

If the patient’s husband could not come to a decision that was in the best interest of the

patient, the hospital’s ethical committee would have to meet. Presented below is the ethical

dilemma and the decision making that would have occurred if the patient’s husband continued to

force the patient to do treatment against her desires.

Ethical Dilemma Versus Statement:


Therefore the versus statement associated with this ethical dilemma is:

Client Self Determination and Quality of Life VS. The Legality of the Medical Power of Attorney.

Ethical Decision Making Model:

To examine the ethical dilemma properly, an ethical decision making model will be used.

Ethics is a branch of philosophy and draws from broader philosophical theories in order to

formulate concepts. Ethical decision making theories were developed to address broad, often

ambiguous issues. While of the ethical decision making concepts differ in some way, they all

consider the value and worth of the human, dignity of life, and the role of happiness, however

this is defined (Rothman, 2013). The most applicable ethical decision making models for this

case are Reamer’s Application of Gawith’s Principles of Hierarchy and Dolloff, Liebenberg, and

Harrington’s Ethical Principles Screen that gives primacy to the NASW Code of Ethics

(Rothman, 2013). This section will analyze the case’s ethical dilemma using both ethical

decision making models.

Reamer’s Application of Gawith’s Principles of Hierarchy:

Reamer bases this model on his interpretation of Alan Gawith’s Principles of Hierarchy,

created in 1994. The hierarchy of principles is based on the fundamental right of all humans to

freedom and well-being (Gawith, 1978, pg. 59-65). Reamer proposes that there are three

categories of core goods that enable or enhance these rights. Basic goods, which are necessary to

well-being, include food, shelter, life, health, and mental equilibrium. Non subtractive goods, the

loss of which would seriously compromise fundamental rights, such as honesty and fidelity in

individual relationships, reasonable labor and comfortable living conditions. Finally, additive

goods, which increase or enhance well-being, such as education, self0esteem, and material

wealth (Rothman, 2013).


In Reamer’s ethical decision making model, there exists six principles of hierarchy.

According to Reamer, the ethical dilemma should be evaluated by analyzing the issue through

principle one and so on. Principle one constitutes rules against basic harms to the necessary

preconditions of action (the core goods, food, health, shelter, etc.) and how these take precedence

over rules against harms such as lying, revealing confidential information (nonsubstractive

goods), or threats to additive goods such as education, recreation, and wealth (Rothman, 2013).

In the case at hand, the condition of the patient’s health or health quality of life take precedence

over other harms such as harming the self-esteem or mental stability of the husband.

Principle two includes that an individual’s right to basic well-being (core goods) takes

precedence over another individual’s right to well-being (Rothman, 2013). Janice’s right to her

basic well-being or desire to end treatment in favor of quality of life vs. quantity takes

precedence over the husbands right to well-being.

Principle three is an individual’s right to freedom and how that takes precedence over his

or her own right to basic well-being (Rothman, 2013). Janice’s right to her freedom, in this case

to choose her end-of-life decisions takes precedence over her right for well-being. In this case,

Janice has the right of freedom of choice when it comes to end-of-life, even if this choice is to

quit treatment.

Next, principle four, is the obligation to obey laws, rules, and regulations to which one

has voluntarily and freely consented ordinarily and how that overrides one’s right to engage

voluntarily in a manner that conflicts with these laws, rules, and regulations (Rothman, 2013). In

this case, Janice is to obey laws and rules of society. The hospital must respect the legal authority

of the power of attorney for medical.


Principle five states that the individual’s rights to basic well-being may override laws,

rules, regulations, and arrangements of voluntary associations in cases of conflict (Rothman,

2013). Conversely, the patient has the right to wellbeing despite laws and rules of society.

Therefore, the patient has the right to quality of life in end-of-life despite the wishes of the legal

medical power of attorney.

Finally, principle six states that the obligation to prevent basic harms such as starvation

and to promote basic public goods such as housing, education, and public assistance overrides

the right to retain one’s own property (Rothman, 2013). This indicates that there is an obligation

to prevent basic harms of the client. In this case, a basic harm of the patient is to continue

treatment, which is painful and not curative and against the desires of the patient. The social

worker and hospital staff have an obligation to try and prevent this.

Therefore, according to this ethical framework, the social worker should advocated for

the least harm of the patient despite possible harms to others around her. While the medical

power of attorney should be honored, it does not stop the social worker and hospital staff from

advocating for the client’s well-being and end-of-life desires.

Dolgoff, Loewenberg, and Harrington’s Ethical Principles Screen: Primacy to the NASW Code of Ethics:

The Dolgoff, Loewenberg, and Harrington’s Ethical Principles Screen gives primacy to

the NASW Code of Ethics. The process induces identifying the problem, and the people,

organizations, and agencies involved, determining the values, goes, and objectives relevant to the

issue held by all who are involve, developing and accessing alternative courses of action,

selecting the most appropriate, and implementing it. If there are relevant sections of the Code

that can provide direction, these must be used. If there are no relevant sections, or if different

sections of the Code give conflicting directions, social workers should apply the Ethical


Principles Screen, which prioritizes seven principles to guide decisions (Rothman, 2013). There

are seven guiding principles in this ethical decision making model. Principle one speaks of the

protection of life. Biological life must always take precedence over any other principles, because

it is in the context of life that ethical decisions are made (Rothman, 2013). In this case, the social

worker and hospital staff are advocating for quality of life at end-of-life. In this way, they are

advocating for quality biological life.

Principle two addresses equality and inequality. Similar circumstances and situations

should be treated the same. However, if there are relevant significant differences, these should be

taken into consideration, and unequal treatment may be accorded where it would lead to greater

equality (Rothman, 2013). When looking at similar situations in practice and in the public

sphere, most individuals advocate for quality of life at end-of-life vs. prolonged, sometimes

painful, life at end-of-life.

Principle three reports on autonomy and freedom. Clients’ autonomy and self-

determination should always be considered, unless their autonomous actions and choices would

threaten the life of self or other. The right to freedom, however, is less compelling than the

prevention of harm or death (Rothman, 2013). Janice has the right to autonomy and freedom of

choice as long as her choices are not harmful to herself or others. Janice wished to end treatment

early which could be seen as a harmful act towards herself. Although, this act could be seen as

her freedom to choose. This is a choice the prevents the further harm of herself by treatment and

allows for quality of life at end-of-life with appropriate hospice care.

Principle four advocates for the least harm. Social workers should avoid causing harm

and prevent harm from occurring to clients or others. Where harm is unavoidable, social workers

should choose the course of least harm, or most easily reversible harm (Rothman, 2013). In this


case, physical harm could occur to the patient if she is forced to continue treatment. While,

psychological harm may occur to the husband if he decides to discontinue treatment for his wife.

Although harm in this situation is unavoidable, the option for least harm and maximum patient

autonomy would be to follow the wishes of the patient and end treatment.

Principle five supports quality of life. Enhancing quality of life for clients and others in

society should be a goal of social work interventions (Rothman, 2013). As stated previously, the

best quality of life for the patient would be to end treatment and return home with hospice care.

In this way, the patient’s wishes are honored and she is made as comfortable as possible with

family present.

Principle six speaks of privacy and confidentiality. There right to privacy of clients and

others should be enhanced wherever possible and in accordance with laws. However, it may be

necessary to break confidentiality when serious harm or death to clients or others may result

from maintaining such confidentiality. Finally, principle seven addresses truthfulness and full

disclosure. Social workers should be honest and provide full and truthful information to clients

and others in order to support a relationship grounded in trust and honesty (Rothman, 2013).

Through this ethical dilemma framework it can be assessed that the best course of action

would be to honor the wishes of the patient. Although harm could occur to the patients husband,

this would be the least harmful with maximum client autonomy for the patient. Therefore, the

social worker and hospital staff should continue to advocate for the patient’s wishes to end

treatment early.

NASW Code of Ethics:

In addition to utilizing Dolgoff, Loewenberg, and Harrington’s ethical decision making

model that gives primacy to the NASW Code of Ethics, it is important to look directly at where


the NASW stands on this ethical dilemma. The ethical dilemma at hand can be categorized as an

end-of-life issue. The NASW “does not take a position regarding the myriad moral and value-

laden questions associated with end-of-life decisions, but affirms the right of individuals to direct

their end-of-life care” (NASW Delegate Assembly, 2006). Therefore, the NASW does not take

an official stance on the ethical decisions that occur in end-of-life care but advocates for client

self-determination. The NASW states that “choice should be intrinsic to all aspects of life and

death. Social workers have an important role in helping individuals identify the end-of-life

options available to them” (NASW Delegate Assembly, 2006). Therefore, the NASW supports

that social workers are to keep intact client self-determination and give patients all of the options

available to them at end-of-life.

In addition, the NASW Code of Ethics supports values that should be taken into account

during this case. The Code of Ethics values the importance of human relationships. In this case,

the value of a strong and supportive relationship between the patient and her husband is essential

for her wellbeing. In addition, the NASW Code of Ethics values the dignity and worth of each

person. In this case, the social worker should protect Janice’s self-determination even though she

is technically incapacitated and to strive for the least harm to the client (NASW Code of Ethics,

2008).

The NASW also describes certain “action steps” that social workers can take when

dealing with end-of-life issues. Specific actions steps that are relevant to this case are; to

facilitate client and family understanding of all aspects and options in end-of-life care, provide

emotional, psychological, social, and spiritual care and services along the end of-life continuum,

provide access to information to facilitate informed consent for decision making, be aware of

client diagnoses and trajectories of illness to best prepare for future health care needs and


decisions, discuss and encourage advance care planning if appropriate, strive to facilitate

continuity of care across all care settings, be knowledgeable about institutional policies on

capacity, advance directives, pain management, futile care, and DNR orders, be able to

differentiate between pain and existential suffering, and act as a liaison with other health care

professionals to communicate clients’ and families’ concerns to the health care team to improve

the quality of end-of-life care (NASW Delegate Assembly, 2006).

The social worker and hospital staff in this case took all of the action steps as suggested

by the NASW. The hospital staff and social worker conducted family care conferences to

facilitate understanding of the options in end-of-life care. Support, access to information, and

listening was provided at all steps of the process. The social worker and hospital staff followed

the NASW Code of Ethics’ suggestions when dealing with this case.

Current Research:

When analyzing an end-of-life ethical dilemma, like the case at hand, it is important to

seek guidance not only from ethical decisions making models and the NASW Code of Ethics but

existing research. In an article from the Cancer Network, researchers Tenner and Heft present

three cases that are intended to prepare practicing oncologists to confront common ethical

dilemmas. The cases they present are when costs of care may be prohibitive for the patient, when

a conflict arises between the patient’s and the family’s preferences for prognostic information,

and when a crucially ill patient with cancer becomes unresponsive and the family is forced to

make the care decisions. It is important to note that Tenner and Heft cite end-of-life decision

making as an important and common ethical dilemma in oncology practice making it even more

beneficial to analyze this case in order to have an understanding for future cases (Peppercorn,

MD, MPH, 2013).


According to the researchers, patients with advanced cancer facing end-of-life appreciate

realistic conversations. Data has shown that patients expect frank discussion of prognosis and

goals of care (Peppercorn, MD, MPH, 2013). These discussions can often change the way the

care is delivered, moving towards greater emphasis on palliative care (Peppercorn, MD, MPH,

2013). Realistic discussions of prognosis are needed early in care to avoid later complications at

end-of-life.

In the case at hand, Janice, her husband, and her care team discussed end-of-life planning

early in her treatment and continued to keep open channels of communication throughout her

treatment. At the hospital, a social worker explains an advance directive during the initial

evaluation of the patient. Patients are encouraged to fill out the medical power of attorney and

living will early on in their treatment to ensure that their wishes will be honored. Janice filled out

the medical power of attorney and the living will early on in her treatment. Janice named her

husband as her power of attorney and decided that she did not want extensive life saving

measures, no feeding tubes, and no ventilators. Janice later signed a do not resuscitate order

which states that no extensive life saving measure will be used if she became unresponsive.

Continued frank and clear discussions of prognosis continued throughout Janice’s treatment.

Although, throughout this process it appeared that her husband did not process the discussions as

fast as Janice did. In these ways, the hospital staff took preemptive measures to ensure that

Janice’s wishes would be honored.

In regards to ethical decision making at end-of-life, Walker, MD, cites four types of legal

cases that exist. These legal cases are (1) the patient with decision-making capacity, (2) the

patient without capacity but who had earlier expressed treatment preferences for end-of-life care

either verbally or in a written advance directive document, (3) the patient without capacity who


had made no prior expression of treatment preferences, and (4) the patient who never had the

capacity to make treatment decisions (Walker, MD, n.d.).

In this case, Janice is considered to be in classification two; the patient is currently

without capacity but had earlier expressed her treatment preferences. In these cases, courts have

ruled that their advance directive wishes should be followed. This is in opposition to the desires

of the appointed medical power of attorney. According to this author’s research, when a

discrepancy arises between the patient’s pre-made end-of-life wishes and the power of attorney’s

current wishes, the court rules in favor of the patient’s end-of-life wishes (Walker, MD, n.d.).

Therefore, if Janice’s husband had continued to want Janice to undergo treatment, her case could

have been taken to court where the court would most likely rule in favor of Janice’s pre-made

wishes regarding end-of-life.

Applicable Case Law:

In addition to current research regarding of end-of-life ethical dilemmas, it is important to

understand the case law relating to these ethical dilemmas and how the right to deny or stop

treatment came to be.

Living Wills and Right to Stop Treatment:

The very first U.S. court case to deal with the issue of end-of-life care was the matter of

Karen Ann Quinlan, a 1976 New Jersey state court case. This cases was used to advance the idea

of Living Wills, by which citizens could authorize their own end-of-life wishes. On April 15,

1975, Karen Ann Quinlan, collapsed, stopped breathing, and slipped into a coma. She had just

arrived home from a party where her friends reported that she took prescription drugs and drank

alcohol after not eating for several days. Doctors were able to save her life, but she suffered

severe brain damage and fell into what doctors diagnosed as a persistent vegetative state. Ms.


Quinlan was thought to be unable to breathe without a mechanical device and she was unable to

eat without a feeding tube (National Center for Life and Liberty, 2015).

After months with no progress, Ms. Quinlan’s family saw no hope for recovery and they

did not want to keep her alive artificially. Her father, who had been appointed guardian, asked

the doctors to remove Ms. Quinlan’s ventilator, but the hospital refused after being warned that

prosecutors could bring homicide charges against them. Ms. Quinlan’s doctors refused to remove

her life support without a court order to protect them. As a result, Ms. Quinlan’s family went to

state court seeking legal protection for the hospital to remove their daughter’s ventilator, where

they won their case (National Center for Life and Liberty, 2015).

In its decision, the New Jersey Supreme Court cited to Roe v. Wade, which had been

decided by the U.S. Supreme Court only three years earlier and had established that every person

has a general constitutional “right to privacy” with regard to medical issues. The New Jersey

Supreme Court ruled that this “right to privacy” was “broad enough to encompass a patient's

decision to decline medical treatment under certain circumstances in much the same way as it is

broad enough to encompass a woman's decision to terminate pregnancy…” (National Center for

Life and Liberty, 2015).

The court held that a competent patient has a constitutional right to choose whether to

accept or discontinue life-prolonging medical treatment. Since Ms. Quinlan was no longer

competent to make this choice for herself, and she had not made this choice while she was still

competent, the court ruled that her incompetence was not an acceptable basis for depriving her of

a constitutional right to refuse medical treatment and die. Therefore, the court permitted her

guardian to make that decision on her behalf (National Center for Life and Liberty, 2015).

Impact of Case Law:


This case illustrates how the right to stop treatment came to be. Although this case is

more drastic than the case at hand they deal with the same ethical dilemma; right to decide end-

of-life care. In this case, Janice indicated per a living well before she was mentally incapacitated,

that she did not want extraordinary measures taken if her death was imminent or if she was in a

persistent vegetative state. Current case law states that Janice’s wishes should be honored and

that if she chooses to end treatment and die, that the hospital staff is not liable for her death.

Although Janice is incapacitated at the end of her life, she still made the decision prior to

not have extensive medical interventions done. Therefore, the hospital staff should work to honor

the decisions of the client. This means that although the patient’s power of attorney wants her to

continue treatment, the hospital staff is responsible for the patient and should protect the

patient’s right to self-determination by honoring that patient’s end-of-life wishes. In regards to

current case law, the hospital staff should try to help Janice’s husband advocate for the wishes of

Janice even if they contradict his wishes.

Current Cases in the News:

Since issues surrounding end-of-life decisions is relatively new, there exist a plethora of

cases in the public news. These cases are important to research to see the public’s opinion of

stopping treatment and to hypothesize possible reactions of the patient’s family and friends.

Children and Teens Refusing Treatment:

In 2015, a 17 year old Connecticut teenager refused chemotherapy treatment for her

Hodgkin’s Lymphoma that had an 85% creative rate. The family wanted to search for alternative

treatments but a judge ordered the teenager to undergo chemotherapy. After two treatments the

teenager ran away from home and was later put into protective custody. The teenager’s mother

stated that it was her decision to refuse treatment, “she does not want the toxins. She does not


want people telling her what to do with her body and how to treat it…They are also killing her

body. They are killing her organs. They're killing her insides. It's not even a matter of dying.

She's not going to die.” The Connecticut Department of Children and Families stated that they

have expert testimony stating that the teenager would die in two years if she does not undergo

chemotherapy treatment. The teenagers lawyer argued for the “mature minor doctrine” which

allows which allows 16- and 17-year-olds in some states to get a judge's permission to make

medical decisions for themselves. But, the court said the patient had not proven mature enough

or competent to make those decisions, citing the fact that she had run away from home (Briggs,

2015).

In this case, the teenager wanted to refuse treatment but was unable to do so as she was a

minor. The courts and child protective services have more authority to hold a person against their

will to complete treatment. If this patient was an adult, it can be assumed that the patient would

have been able to make her decision and refuse treatment. This case upholds current case law

stating that adults can refuse treatment if they are competent to make the decision. Since the

child was not an adult child protective services can intervene to do what is best for the child.

Another current case involves a 50 year old mother of three from London who refused

kidney dialysis treatment because she did not want to “lose her sparkle” and become “poor, ugly

or old.” The court in London heard the case after the patient tried to overdose to take her own

life. The patient’s hospital wanted the judge to rule that it would be in her best interests if

treatment was imposed and restraint was used if necessary. The court decided that the woman

has the mental capacity to refuse treatment. A court spokesperson stated that “Her decision is

certainly one that does not accord with the expectations of many in society…Indeed, others in

society may consider her decision to be unreasonable, illogical or even immoral within the


context of the sanctity accorded to life by society in general…None of this, however, is evidence

of a lack of capacity” (Clarke-Billings, 2015).

According to this current case, the patient was able to make her own decision regarding

her care even if it was contrary to popular beliefs. Also, this case upholds that notion that adults

can make their own decisions regarding treatment and ending treatment as long as they are of

sound mental capacity.

Finally, a very recent and public case regarding the right to end treatment involved two

country singers couple. Joey and Rory Feke are a couple and up and coming country stars with a

large fan base. Joey, the women, has been battling cancer for a long time. Her cancer came back

and she underwent extensive surgery and chemotherapy. The therapies were not working as a CT

scan revealed two tumors in areas already treated by chemotherapy and radiation. In a statement

made via their blog the couple shared, “So we did what you do when the medicine isn’t working,

and the doctors are at a loss…and when the ‘statistics” say you can do more chemo, but it will

only buy you a little time…We came home. Not to die. But to live” (Whitaker, 2015). The

country couple is very faithful and put their trust and faith in God stating that they “prepare for

what God has put in front of us…” (Whitaker, 2015).

This current case is most similar to the case at hand. Janice and Joey are both facing

advanced cancers with treatments that are not working. Both could continue treatment to “buy

more time” but the treatment is palliative, not curative. Joey was of sound mind and made the

decision to end treatment and be home with hospice care. Janice was not of sound mind but had

made comments about how she was “done” with treatment. Janice also had indicated in her

living will that she did not want extensive measures taken if her death was imminent. Although


this does not specifically state she wanted to stop treatment, it eludes to the fact that, if she was

of sound mind, she would not want to continue with aggressive treatments.

Societal Values:

From observations of current and past publicized cases like Janice’s case, society’s

opinion of this ethical dilemma is varied. For example, society majorly disapproves when a

person is taken off of life-support or a ventilator and consequently passes away (National Center

for Life and Liberty, 2015). Conversely, society is more accepting and sometimes sees it as

honorable that a person decides to end treatment early (Whitaker, 2015). In Janice’s cases,

society would be accepting of her and her husband’s decision to end treatment early.

Agency and Staff Values:

Mission, Vision, Values of Hospital System:

The hospital’s mission statement is “committed to living out the healing ministries of the

Judeo-Christian faiths by providing exceptional and compassionate healthcare service that

promotes the dignity and well-being of the people we serve” ([The Hospital], 2004). The vision

statement states “The health ministries of [the hospital] will be recognized in each community it

serves for superior and compassionate patient service, for clinical excellence, and for being the

healthcare employer of choice and the preferred partner of physicians” ([The Hospital], 2004).

The hospital also promotes shared values that are to bring to live the mission. These

values are: “integrity; we are consistent and honest in word and deed, respect; we behave in a

way that honors self and others, quality, we provide service excellence in meeting customers’

expectations, Commitment; we demonstrate dedication to our work, personal development, the

organization, the mission and the vision, and accountability; we follow through and are

answerable for our performance” ([The Hospital], 2004).


The mission and vision statement and the values dictated how the hospital approaches

patient care and ethical dilemmas like present in this case. When creating hospital policy, each

policy begins with how the subsequent policy will address and uphold the mission, vision, and

values of the hospital. The mission, vision, and values are also instilled into new employees

during employee orientation. The hospital system places a high value on following the mission,

vision, and values from administration to patient care ([The Hospital], 2004).

Catholic Church Affiliation:

The hospital is affiliated with the Catholic Church. Although, this affiliation does not

prohibit members of other faiths from receiving the same quality of care as others. Nevertheless,

the Catholic Church is still affiliated with the hospital and it is therefore necessary to analyze

where the Catholic Church stands on end-of-life issues (Catholic Health Association of the

United States, n.d.).

Most of the knowledge base of the stance of the Catholic Church on these issues comes

from the Ethical Directives for Catholic Health Care Services. This is a document which guides

the practice of Catholic affiliated hospitals, long term care facilities, and other Catholic health

care organizations. According to this and other documents, the Catholic Church affirms that

there is a long standing moral theology that speaks of “reasonable care in terms of the benefits of

such treatments being proportionate to the burdens that the treatments impose.” The Catholic

Church offers two extremes to avoid regarding end-of-life issues; intending the death of a patient

by assisted suicide and continuing useless or excessively burdensome treatments. The Catholic

Church advocates for a middle ground on these issues (Catholic Health Association of the United

States, n.d.).


The term “burden” is defined by the Catholic moral tradition as having four aspects. They

are excessive pain, great cost or means to the patient, grave effort excreted by the patient, and an

intense fear or repugnance for the treatment may make an ordinary treatment an extraordinary

treatment for certain patients (Catholic Health Association of the United States, n.d.).

The Catholic Church states that one has the duty to preserve life but this duty is not

absolute. In the Vatican’s 1980 document entitled Declaration on Euthanasia Part IV states that

“one cannot impose on anyone the obligation to have recourse to a technique which is already in

use but which carries a risk or is burdensome? Such a refusal is not the equivalent of suicide; on

the contrary, it should be considered as an acceptance of the human condition” (Catholic Health

Association of the United States, n.d.).

Therefore, the Catholic Church, which is affiliated with the hospital, advocates for a

middle ground between assisted suicide and excessive treatment that creates undue burden for a

patient. In the current case, Janice’s husband could be considered to be putting his wife under

undue burden or excessive treatment for Janice’s terminal cancer. The Catholic Church would

support Janice’s pre made decision to not utilize drastic life-sustaining measures.

Perceived Values of Cancer Center Staff:

The Cancer Center staff at the hospital also share common and unique values. The overall

value system of the Cancer Center is that of patient centered care and patient self-determination.

The doctors, nurses, social workers, and other Cancer Center staff advocate strongly for the

physical, mental, and emotional health of each patient. In addition, the radiation oncologist is

very determined to have every patient understand and fill out an advance directive and living

will. Some members of the staff are religious; mostly all are of the Christian faith. The author

has not yet observed that this has impacted the type of care that is given to each patient. The faith


background of the staff does not appear to influence the practice. The values held by the staff

patient self-determination and overall quality of life.

Personal Values:

The author holds values that are similar to the values held by the NASW. The author

values client self-determination and well-being. The author values the overall quality of life of a

patient over the quantity of life. In this way, the author agrees with and values the desire to end

treatment early and to live the rest of one’s life with quality and family near.

Client and Family Values:

The patient was a recently retired wife and mother. The patient and her husband were

planning to travel and enjoy retirement together but she was diagnosed with cancer soon after her

retirement. The family indicated that they were Catholic but they were not strictly religious or

very active in the church. The family was spiritual in that they believed in God and life after

death. The patient’s husband had a difficult time accepting the severity and immediacy of his

wife’s condition. This appeared to be the biggest obstacle in helping the patient’s end-of-life

wishes is honored. The patient valued the life of his wife and their relationship. He loved her

very much and truly wanted to do what was best for her.

Options for Action:

Option One: Continued Family Care Conferences:

The first option for action in this case would be to continue the family care conferences

with the patient, husband, and hospital staff. Family care conferences are requested by the family

or the hospital staff. The family and all concerned staff are involved for a conversation about the

patient’s diagnosis, prognosis, and quality of life. The hospital staff had already completed

several care conferences by this time. More care conferences would help the husband work


through his grief and the severity of his wife’s diagnosis; helping him to see what is really in her

best interest. Conversely, these family care conferences could continue to produce no new

decisions from the husband. In this way, the patient would continue treatment that she did not

desire to do.

Option Two: Ethics Committee Intervention:

Since the family care conferences were not yielding new decisions from the husband, the

hospital ethics committee could become involved. An ethics committee consultation serves the

purpose to “identify bioethical problems in the care of a particular patient, to analyze these

bioethical problems through careful dialogue, and to facilitate resolution of bioethical problems

through a process of shared decision making with those most involved.” A request can be made

from the family member or the hospital staff involved. This can be done in an informal or formal

matter and those it concerns are not obliged to participate. The purpose of the ethical committee

consultation is to provide guidance on how to deal with a particular ethical dilemma.

The hospital staff involved could request an ethical consultation to help them decide how

to handle the patient’s ethical dilemma. In addition, the ethical consultation could be requested

by both the family and the hospital staff to discuss the situation and, hopefully, come to a

resolution.

This option for action provides more structure and additional hospital staff to provide

guidance on the ethical dilemma. This may signal to the patient’s husband that her situation is

dire and he must act for the well-being of the patient. Conversely, the addition of more hospital

staff may upset the patient and her husband. The husband may feel that he is being scolded or

being told he does not know how to care for his wife. This may make the husband more upset

and keen to follow what he thinks is best for the patient. This solution could hinder the


relationship with the husband and further push him to do what he thinks is best for the patient

(continue treatment). Or, this solution could signal to the husband that his wife’s condition is dire

and to do what she desires and end treatment.

Option Three: Legal/Court Intervention:

According to Walker, MD, four types of legal cases regarding end-of-life ethical decision

making exist. One of these legal cases is when the patient is without capacity but had earlier

expressed treatment preferences for end-of-life care either verbally or in a written advance

directive document. In these cases, courts have ruled that their advance directive wishes should

be followed. This is despite the desires of the appointed medical power of attorney. According to

this author’s research, when a discrepancy arises between the patient’s pre-made end-of-life

wishes and the power of attorney’s current wishes, the court rules in favor of the patient’s end-

of-life wishes. Therefore, if Janice’s husband had continued to force Janice to undertake

treatment her case could have been taken to court where the court would most likely rule in favor

of Janice’s pre-made wises regarding end-of-life.

Therefore, the hospital staff has the option of taking Janice’s case to court to contest the

power of attorney. This option is very drastic and would most likely harm the existing

relationship with the husband. This would cause undo harm on the psychological well-being of

the husband. In addition, this would be a very time consuming process which would likely not

resolve in needed time for the patient. It would also force the patient’s husband to take attention

away from being with his wife at end-of-life and instead focus on the court case. This would

cause undo harm on the patient because she would not have the full attention of her loved ones as

she passed away.

Option Four: Honor the Power of Attorney:


Finally, the hospital staff could simply honor the power of attorney and let the husband

continue to force his wife to do treatment. The hospital staff did try to help the husband see the

patient’s true wishes through multiple family care conferences. This option seems logical as the

hospital tried but, the power of attorney does have the final say in the care of the patient. While

this is true, the hospital staff and social worker are to advocate for the well-being and self-

determination of the client. To let the husband continue to make the patient undergo treatment

would be to not advocate for the well-being and self-determination of the patient.

Dilemma Resolution:

While these four options are viable solutions, the author would choose option one. Option

one presents the least harm to the patient and the husband while advocating for the patients well-

being and self-determination. If option one continues to produce no new results from the

husband and the patients time and well-being are running out, then option two may be a viable

option. This is not the first option to consider as it may harm the relationship between the

husband and the hospital staff. This would harm the psychosocial wellbeing of the husband

which would affect the patient. In addition, the husband may become upset with the hospital staff

and then continue to do what the thinks is best for the patient.

Option three is too drastic of an option for this case. The patient’s prognosis is not very

long and the goal is to give the patient the best quality of life possible. This option would cause

the husband undo harm and cause him to not focus all of his attention to the patient, which would

cause her harm. This option would affect both the husband and the patient’s psychological well-

being. This option does not advocate for the well-being of the patient. Therefore, this option was

not chosen. Finally, option four was not chosen as it did not fully advocate for the clients well-

being and self-determination. The hospital staff did try to help the husband realize his wife’s true


wishes but, since he is the legal medical power of attorney, he can do what he thinks is best.

Although this is true, the hospital staff and social worker should continue to advocate for the

patient’s wishes, well-being, and self-determination. Therefore, this option was not chosen.

Option one, continued family care conferences, would allow the husband some time to

work through his grief and come to his own conclusion of what to do in regards to his wife’s

treatment. This solution would protect the psychological well-being of both the patient and the

husband. The husband is able to work through his grief with a supportive hospital staff and the

patient will be able to end treatment with her husband’s full attention. For these reasons, option

one would be the best option for action in this case.

Actual Case Resolution:

Since this case is from November 2015, the case was resolved. In the actual case, the

hospital staff and the Cancer Center Social Worker chose option one which is parallel with the

option the author chose. In the actual case, the Cancer Center Social Worker met with the patient

and her husband and found that the patient’s husband was upset that the patient had given up.

They had been planning their retirement together and did not get to enjoy it. After further

analysis it was clear that the patient’s husband had not processed his grief as fast as his wife did

and not as fast as her disease was progressing. According to Elisabeth Keebler-Ross, there are

five stages of grief normally experienced when facing a trauma. Everyone spends different

lengths of time in each stage and may not experience every stage. The stages of grief are denial

and isolation, anger, bargaining, depression, and acceptance (Axelrod, n.d.).

The patient and her husband moved through the stages of grief. At the beginning of her

diagnosis they were hopeful for a cure or a miracle even though the diagnosis was not very good.


The patient moved through the stages into a stage of depression and being done to the stage of

acceptance when she spoke of wanting to end treatment.

The patient’s husband did not reach acceptance until much later. He often spoke of how

he was upset that his wife wanted to end treatment. He often spoke of hoping for a miracle and

thinking something could still save her life although she eventually moved into palliative

treatment that would only give her a couple of months or a year. The patient’s husband stayed in

the stage of denial for a long time regarding his wife’s diagnosis and prognosis. After further

family care meetings, the husband honored the patients desires and they went home with hospice.

The patient died on November 25th 2015.


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Advanced cancer patient’s wishes at end-of-life: An ethical dilemma

Social Work Senior Seminar

Gabrielle Lynn Cypher

4/25/2016

SOCIAL WORK THESIS GCYPHER

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