Question

The Case of Marion and the Pacemaker

Marion is a 92-year-old patient who weighs 78 pounds. She has had poor eating habits for at least 20 years and refused all attempts by her two daughters to improve her nutrition. In addition, Marion had been a heavy smoker all her life and suffered frequent respiratory problems. During the past two years she has become quite forgetful, has suffered a broken hip as a result of a fall out of bed, and has been treated for pneumonia. Her daughters, who have their own family responsibilities and cannot bring their mother to live with them, have found an excellent nursing home near them. In spite of Marion’s protests, she enters the nursing home. However, she quickly adjusts to her new home and likes the care and the attention that she receives.

During her third week in the nursing home, Marion develops a cough, high temperature, and respiratory problems. She is hospitalized with a diagnosis of pneumonia. Marion immediately becomes disoriented and attempts to remove her intravenous and oxygen tubing. Since she tried to climb out of bed, her daughters must remain at her side. The attending physician tells the daughters that in addition to treatment for pneumonia, Marion will also need to have a pacemaker inserted to regulate her heartbeat. Marion would then be unable to return to the nursing home since the facility is not equipped to care for someone recovering from surgery.

One of Marion’s daughters has been granted a medical power of attorney for her mother. Before Marion became confused, she clearly explained to her daughters her wishes not to receive extraordinary measures to prolong her life. She also signed a living will indicating her wishes. After thoughtful discussion with other family members, Marion’s daughters tell the physician that they do not want to put their confused mother through the surgical procedure. They state that they want to spare her the pain of recovery from a surgical procedure since she is quite confused and elderly. Further, they are concerned that their mother will not survive an anesthetic and a surgical procedure in her frail condition.

The physician seems to be understanding of this decision. He says that he will place their request in Marion’s chart not to have the pacemaker inserted. However, the floor nurses take the daughters aside on several occasions to tell them that this is not a dangerous procedure and that they need to sign a permit for surgery. In fact, the nurses make the daughters feel that they are not acting in their mother’s best interests by not signing the surgical permit. Marion returns to the nursing home without a pacemaker. She lives another four years without any cardiac problems.

Case Questions

1. Were the nurses carrying out their responsibility as licensed healthcare professionals or were they overstepping their role?

2. Were Marion’s daughters acting in the best interests of their mother since they knew that if she had the surgery she could not return to the nursing home where she was receiving good care?

3. What should happen when a physician agrees with the family members and the nursing staff does not?

Answer 1

Ans) 1) I would have to say the nurse was overstepping. Once the medical heard the mother's wishes that should have been the end of discussion. I understand the medical staff just wanted the best for patients but you can go against their wishes. I think once the doctor acknowledged the wishes the nurse should have followed suit. The nurse was more so pushing what she wanted on to the daughters.

2) I don't think their opinion was based off the fact that she couldn't go back to the nursing home after the procedure. If they were selfish and didn't want to take care of her than I can see that but their there so they are obviously love her. I just see too girls caring out what their moms wishes. I am sure they have their opinions on her not getting the surgery but it's her life not theirs.

3) I don't think the nurse's opinion matters to family. It may matter to the doctor so if she wants she can pull the doctor aside and plead her case. However her thoughts still would matter, the patient as already made their mind. Hats like trying to give someone a cookie their allergic to, they already know to avoid the cookie, they also know the outcome of eating the cookie and you keep pushing them to try it.