Case: Miss Diasy is an 85-year-old economically disadvantaged woman who lives al
ID: 194233 • Letter: C
Question
Case: Miss Diasy is an 85-year-old economically disadvantaged woman who lives alone, has no car and cannot take public transportation because she cannot stand or walk without her walker or a store scooter. She lives only on what she collects from Social Security and has no family to care for her. She has a few well-intentioned neighbors and does have access to a senior center that can transport her to the grocery store, but lately she has no desire to grapple with the energy it takes for her to shop. She now relies on Meals on Wheels. She can usually find someone to take her to her medical appointments maybe once or twice a week but does not have anyone to shop, clean, do laundry, cook, pay bills or run errands for her (Medicare/Medicaid will not pay for these services). Along with severe high blood pressure and heart disease, Miss Daisy has been diagnosed with end-stage kidney disease. Though dialysis is an option, it would require many trips to the dialysis center each week (4 – 5 times a week), and is extremely difficult and unpleasant for patients in her condition. Because of her overall health condition, she would not be eligible for a kidney transplant, as she couldn’t survive the surgery. Her situation is dire, and most doctors agree the end of her life is near. It is unclear what Miss Daisy wants, and she is looking to the doctors to help guide her decisions. Case Questions (to be answered in ESSAY FORMAT): If one were going to ration care based on age, Miss Daisy would only be given comfort (or “palliative” care), but not dialysis. What would be the reasoning behind this care plan? That is, explain how someone arguing in favor of rationing care to the elderly would justify nontreatment for Miss Daisy’s kidney disease. Another way to put it is: give the argument for why non-treatment or withholding dialysis and transplant (but continued medical care for symptoms, comfort, nutrition, etc.) is the right choice. Now, decide whether you agree with rationing based on age, or if you think other factors along with age need to be considered, being sure to give your reasons/arguments in essay format. That is, is it just her age that’s the problem, or are there other important factors playing a role in determining her medical treatment options? Finally, argue for what you believe would be the best, most compassionate or most virtuous course of action for Miss Daisy, including what should be said to her by her doctors when she asks them for advice, using any and all principles and concepts we’ve covered this semester.
Your complete essay should be about 2 - 3 pages long. Remember that you should be referencing the principles we’ve studied from other chapters – beneficence, nonmaleficence, autonomy, and justice – and should be making clear to the reader that you understand the real moral problems embedded in this case.
Explanation / Answer
Miss. Daisy is 85 years old. Older people on dialysis have a significantly shortened life expectancy. This is especially true when they have multiple illnesses.
She was unable to do dialysis, because it costs lot of money.
Miss. Daisy is alone and nobody is there to take care of her. Patients under dialysis treatment or organ transplantation must be in diet and the amount of fluid you drink needs to be restricted. If, she is haemodialysied, she must avoid certain foods and are usually advised not to drink more than a couple of cups of fluid a day.
Miss. Daisy may get Fatigue, feeling tired and exhausted all the time, is a common side effect in people who use dialysis on a long-term basis.
Low blood pressure is one of the most common side effects of haemodialysis. It can be caused by the drop in fluid levels during dialysis.
She may be at increased risk of developing sepsis (blood poisoning). This is where bacteria enter the body and spread through the blood, potentially leading to multiple organ failure.
Each session typically lasts approximately 4 hours, so at least 12 hours each week should be reserved for dialysis treatment and other activities should be planned around this. She is unable to come because she is not having car.
In patients who receive dialysis, there is higher risk of cardiovascular diseases and mortality than the general population. Patients who receive renal transplantation have been shown to have improved cardiovascular survival. When studying the effect of high blood pressures, 50 to 60 percent of the patients on hemodialysis are hypertensive and the value can be as high as 85 %. She was already in risk of cardiac disease and high blood pressure.
Patients with end-stage renal disease (ESRD) on long-term dialysis therapy have very high mortality due to predominantly cardiovascular causes. Sudden cardiac death (SCD) is the single most common form of death in dialysis patients. These patients indeed have a very high burden of coronary artery disease (CAD), and a proportion of SCD events could be due to obstructive CAD.
Many patients die in the first year of dialysis, and 46% of those deaths occur in the first 4 months, primarily from cardiovascular disease, infection, liver disease, and withdrawal of treatment. One-year survival on dialysis is associated with several risk factors including lack of pre-ESRD care, positive HIV status, diabetic status, and low serum calcium levels.
Cancer screening should be appropriate for age and co morbidity and targeted to malignancies seen in transplant patients.
Cardiac disease is the major cause of death in ESRD patients but no randomized, controlled trials have been done to clarify best practices.
Cardiac serum markers and diagnostic tests have a high level of false-positive results in ESRD patients and require care in interpretation. This will be expensive.