Case example

Thirty-five-year-old Ted Jones is brought to the ED of a small rural hospital one afternoon by his partner, James Moore. Mr. Jones was diagnosed with HIV infection ten years ago, and with AIDS two years ago. He has had multiple medical problems over the past two years, including several opportunistic infections. His presenting symptoms today are shortness of breath, chest pain, cough, and fever. He appears tired and emaciated, and he reports a two-week history of fatigue and weight loss of 8 lbs.

Despite his discomfort and fatigue, Mr. Jones is alert and oriented. Dr. Turner, the emergency physician on duty, administers a brief mental status exam; he observes that Mr. Jones has difficulty counting backwards from one hundred by sevens, and cannot accurately copy a geometric design. Mr. Moore, his partner for the past five years, reports that Mr. Jones has become increasingly tired, forgetful, and unable to concentrate over the past six months. Dr. Turner strongly suspects that Mr. Jones has Pneumocystis pneumonia (PCP). Dr. Turner requests a sputum sample for testing and recommends immediate initiation of targeted therapy to treat the suspected infection. Mr. Jones responds, however, that he does not want specific drug treatment if he has pneumonia. He maintains that he is tired of living with AIDS and wants to be allowed to die. He adds that he agreed to come to the hospital only because the pain and difficulty breathing became too great, and asks that he be given only treatment to relieve his pain and make him comfortable.

Mr. Moore, however, urgently requests that his partner be given definitive therapy for his lung condition. If Mr. Jones has PCP, Dr. Turner believes that prompt initiation of IV antimicrobial treatment has a 70–80 percent chance of treating his infection successfully. If Mr. Jones has PCP and it is left untreated, he will have progressive respiratory symptoms that will lead to death in a few days. How should Dr. Turner proceed?

In this chapter, we continue the examination of moral issues in medical treatment near the end of life. Chapter 15 described advance care planning, a strategy designed to prevent moral conflicts over end-of-life care by identifying and honoring the patient's own treatment preferences.