1. RUNNING HEAD: ADVANCED CANCER PATIENT’S WISHES AT END-OF-LIFE 1
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
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“patient appears withdrawn, no eye contact made, when asked how patient doing, no response,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
2. 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
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:
3. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 3
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).
4. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 4
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
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.
5. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 5
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
6. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 6
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
7. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 7
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
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
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
8. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 8
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,
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
9. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 9
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.
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).
10. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 10
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
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
11. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 11
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.
12. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 12
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:
13. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 13
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
14. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 14
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,
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
15. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 15
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
16. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 16
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.
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).
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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
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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
19. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 19
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.
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
20. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 20
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
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
21. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 21
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:
22. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 22
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.
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
23. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 23
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.
24. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 24
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.
25. ADVANCED CANCER PATIENT’S WISHES AT END OF LIFE 25
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Advanced cancer patient’s wishes at end-of-life:
An ethical dilemma
Social Work Senior Seminar
Gabrielle Lynn Cypher