Assessment 3: Should We Withhold Life Support? The Mr. Martinez Case

The Patient’s Directives

Mr. Martinez’s case presents a complex ethical dilemma concerning end-of-life decisions and the limitation of life support. The presence of a Do Not Resuscitate (DNR) order in his medical records indicates that he and his wife had previously decided against resuscitative measures, including cardiopulmonary resuscitation (CPR). This directive aligns with the principle of patient autonomy, which grants individuals the right to refuse medical treatment, even if it results in death (National Institute on Aging, 2022): Assessment 3: Should We Withhold Life Support? The Mr. Martinez Case.

However, since Mr. Martinez is currently unable to communicate his wishes, his advance directive should serve as the guiding principle in medical decision-making. The key ethical issue is whether the directive extends to withholding a ventilator in the current crisis, given that it was not explicitly mentioned.

The Patient’s Quality of Life

A fundamental ethical consideration in withholding life support is the patient’s expected quality of life. Mr. Martinez, a 75-year-old with chronic obstructive pulmonary disease (COPD), was already experiencing compromised respiratory function. His condition had worsened due to an upper respiratory infection, leading to respiratory failure. Given his preexisting illness, the use of a ventilator may only prolong suffering rather than significantly improve his condition.

The ethical principle of beneficence suggests that medical interventions should aim to benefit the patient, while nonmaleficence emphasizes the need to avoid causing unnecessary harm (Varkey, 2020). If continued treatment is unlikely to restore meaningful function and merely prolong the dying process, it may not be in the patient’s best interest.

The Family’s Stated Preferences

The preferences of the patient’s family often play a crucial role in end-of-life care, especially when the patient cannot communicate. In this case, Mr. Martinez’s wife had previously agreed to the DNR order, suggesting that she understood and supported his desire to forego resuscitative measures. However, as the doctors cannot currently reach her, they must make an ethically sound decision without her direct input.

In such cases, medical professionals rely on the principle of substituted judgment, which involves making decisions based on what the patient would have wanted rather than what the family or clinicians believe is best (Arras, 2020). If Mrs. Martinez had previously affirmed her husband’s wishes, it is reasonable to assume that she would support withholding life support in this situation.

Moral Issues Associated with Limiting Life Support

The decision to withhold life support raises several moral concerns, particularly regarding the distinction between allowing a natural death and actively hastening death. Passive euthanasia, which includes withdrawing or withholding life-sustaining treatment, is legally and morally distinct from active euthanasia, which involves direct intervention to cause death (Reignier et al., 2019). In this case, withholding a ventilator does not constitute active euthanasia; rather, it respects Mr. Martinez’s prior decision to limit life-sustaining interventions. The challenge arises in ensuring that such decisions are made ethically, with consideration for both medical prognosis and the patient’s stated values.

Ethical Principles Relevant to Decision-Making

The ethical principles that guide decision-making in this case must be examined closely and thoroughly understood. The principle of autonomy, which underlies modern medical ethics, extends beyond respect for patient choice to encompass the more fundamental concept of moral self-determination (Varkey, 2020). Autonomy in Mr. Martinez’s case manifests itself in the form of his advance directive, but its application must be interpreted with caution.

When a patient is acting independently by executing an advance directive, he or she is making forward-looking decisions – choosing future conditions based on his or her values and beliefs. This raises important questions of whether the directive should be construed narrowly (applying only to treatments expressly mentioned) or broadly (applying to analogous treatments expressing the patient’s declared values).

The beneficence ethics here require more than simply promoting good outcomes – they require healthcare providers to proactively pursue the patient’s best interest in the context of their own understanding of benefit. In Mr. Martinez’s situation, beneficence needs to be understood in the context of his previous statements about the quality of life and what he desires concerning life-sustaining treatment.

This principle operates interactively with non-maleficence, which is more than the simple maxim of “first, do no harm.” Non-maleficence in modern medical ethics requires careful consideration of what constitutes harm in the context of life-sustaining treatment. The harm of prolonging suffering through coercive intervention must be weighed against the harm of allowing advance a potentially reversible condition.

Subsequently, healthcare justice transcends fair distribution of resources to encompass matters of equity and adequate standards of care (Varkey, 2020). In the case of Mr. Martinez, justice encompasses consideration at the individual and societal levels. At the individual level, justice requires Mr. Martinez to receive adequate care according to both his wishes and medical standards.

At the social level, justice involves considering how intensive care resources are utilized here might affect other patients’ ability to access care. This multi-layered concept of justice is what helps to guide the ethical decision-making process.

The principle of proportionality, which might be too readily dismissed in preliminary ethical thought, is precisely relevant in this case. The principle requires that treatment burdens must be proportionate to what their benefits ought to be. For Mr. Martinez, the hazard of mechanical ventilation – of inconvenience, problems, and dying longer – must be weighed against the hope for full recovery. This principle bridges the chasm between normative ethical thought and actual medical choice.

Moreover, the virtue of veracity (truthfulness) bears on these other virtues in substantial ways. Despite Mr. Martinez’s inability to speak currently, the virtue of veracity calls for truthful attestation of his prognosis and faithful compliance with the interpretation of his previously expressed wishes. This entails speaking truthfully about the boundaries and potentialities of life-sustaining treatments.

Important Considerations and Potential Conflicts

In determining whether to withdraw life support, medical professionals must balance a number of important factors. One of these factors, which is of great importance, is whether the accidental increase in Mr. Martinez’s oxygen level, which precipitated his respiratory failure, triggers an ethical obligation to attempt to reverse it. While this error accelerated his decline, it does not necessarily outweigh the patient’s prior directive.

In addition, there may be a conflict between the duty of the medical team to respect patient wishes and the desire to preserve life. Ethical principles, including principlism and virtue ethics, help direct decision-making in such ethically complex situations (Arras, 2020).

Conclusion

Mr. Martinez’s situation highlights the ethical complexity of withholding life support in end-of-life care. His advance directive, quality-of-life consideration, autonomy standards, beneficence, and nonmaleficence all support withholding life support as being consonant with an ethically responsible response. Despite the absence of direct family feedback adding a degree of complexity to the situation, the medical staff has to decide by ethical rationale and best practices for end-of-life care. By prioritizing patient autonomy and the relief of suffering, physicians can make such hard choices with integrity and compassion.

References

Arras, J. (2020). Theory and Bioethics (Stanford Encyclopedia of Philosophy). Stanford.edu. https://plato.stanford.edu/entries/theory-bioethics/

National Institute on Aging. (2022). Advance care planning: Advance directives for health care. National Institute of Aging. https://www.nia.nih.gov/health/advance-care-planning/advance-care-planning-advance-directives-health-care

Reignier, J., Feral-Pierssens, A.-L., Boulain, T., Carpentier, F., Le Borgne, P., Del Nista, D., Potel, G., Dray, S., Hugenschmitt, D., Laurent, A., Ricard-Hibon, A., Vanderlinden, T., & Chouihed, T. (2019). Withholding and withdrawing life-support in adults in emergency care: joint position paper from the French Intensive Care Society and French Society of Emergency Medicine. Annals of Intensive Care, 9(1). https://doi.org/10.1186/s13613-019-0579-7

Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

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Instructions
Write a 2–3 page paper that examines the moral and ethical issues involved in making a decision regarding limiting life support.

End-of-Life Issues
With our framework of ethical theories and principles in hand, we begin our look at some of the critical ethical issues in our contemporary world, starting with end-of-life issues. This assessment covers ethical questions related to end-of-life care. Passive euthanasia is the removal or refusal of life-sustaining treatment. Examples of passive euthanasia include removal of a feeding tube or a ventilator, or forgoing a life-prolonging surgery.

Passive euthanasia is legal in all 50 states, and the principle of autonomy gives informed patients the right to refuse any and all treatments. Patients who are unable to make such decisions in the moment (because they are unconscious, for example) might have made their intentions clear beforehand with an advance directive or similar document.

Things become more complicated, however, when a patient who is unable to make treatment choices has not made his or her wishes clear, either formally in a written document, or informally in conversations with family members or friends. Another problem concerns cases in which there is disagreement about whether the treatment is sustaining the life of a person in the full sense or merely as a body that, because of severe and irreversible brain trauma, is no longer truly a living person.

Active euthanasia, or assisted suicide, introduces further difficult moral questions. A patient who has a terminal illness and who has refused treatments that would merely prolong a potentially very painful and debilitating death might want the process of dying to be hastened and made less painful. The patient might want to take his or her own life before the disease reaches its horrible final stages. Should patients be legally allowed to have help in this endeavor?

If suicide itself is not morally wrong, at least in cases like these, is it wrong for another person to directly help bring about the patient’s death? Is it wrong for doctors, a role we naturally associate with healing and the promotion of life, to use their medical expertise to deliberately end a patient’s life if the patient wants this?

Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Articulate ethical issues in health care.
  • Articulate the moral issues associated with limiting life support.
• Competency 2: Apply sound ethical thinking related to a health care issue.
  • Demonstrate sound ethical thinking and relevant ethical principles when considering limiting life support.
  • Explain important considerations that arise when contemplating limiting life support.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals.
  • Exhibit proficiency in clear and effective academic writing skills.
    

    Assessment 3: Should We Withhold Life Support? The Mr. Martinez Case

Preparation
Case Study: Mr. Martinez.
This media piece provides the context for this assessment; make sure you have reviewed the case study thoroughly.

• Mr. Martinez was a seventy-five-year-old chronic obstructive pulmonary disease patient. He was in the hospital because of an upper respiratory tract infection. He and his wife had requested that CPR not be performed should he require it. A DNR order was written in the charts.
  In his room on the third floor, he was being maintained with antibiotics, fluids, and oxygen and seemed to be doing better. However, Mr. Martinez’s oxygen was inadvertently turned up, and this caused him to go into respiratory failure. When found by the therapist, he was in terrible distress and lay gasping in his bed.

Additionally, it may be useful to think through the following issues as they relate to Mr. Martinez’s case:

• Should Mr. Martinez be transferred to intensive care, where his respiratory failure can be treated by a ventilator, and by CPR if necessary, and his oxygen level can be monitored?
  • What are the key ethical issues or models at play in this case study?
  • What are the key end-of-life issues at play in this case study?
  • How can an understanding of models and best-practice help to guide health care practitioners to make ethical and legal decisions?

Instructions
In a 2–3 page analysis of the case study, address the following:

• The patient’s directives.
• The patient’s quality of life.
• The family’s stated preferences.
• The moral issues associated with limiting life support.
• The ethical principles most relevant to reaching an ethically sound decision.
• Important considerations such as implications, justifications, and any conflicts of interest that might arise because of the patient’s respiratory failure.

When writing your assessment submission assume that doctors cannot contact Mrs. Martinez and must make this choice on their own. To help you reach an objective, ethically sound decision, draw upon concepts and arguments from the suggested resources or your independent research. Support your response with clear, concise, and correct examples, weaving and citing the readings and media throughout your answer.

Submission Requirements

• Written communication: Written communication is free of errors that detract from the overall message.
• APA formatting: Resources and citations are formatted according to current APA style and formatting guidelines. Refer to Evidence and APA for guidance.
• Length: 2–3 typed, double-spaced pages.
• Font and font size: Times New Roman, 12 point.