Mr. Z is a 79-year-old African-American man with a history of diabetes and heart disease. He has been in and out of St. John's Hospital for the last eight months. On his last admission it was discovered that he had an infected left hip that required the removal of the hardware from his previous hip replacement surgery and aggressive antibiotic treatment to stem the infection that had developed. After being home for nearly four weeks, Mr. Z was brought back to the hospital by his son because of a high fever and intense, diffuse pain. It was discovered that the infection had reoccurred and that his leg, on the same side as the hip complications, was gangrenous. Based on Mr. Z's instructions, nothing aggressive (e.g., amputation) was to be done to the leg. However, he did consent to further antibiotic treatment and to relatively high doses of morphine for the pain. As time went by, the infection proved resistant to the medications and Mr. Z's pain increased. His attending physician was alerted to this but was hesitant to increase the dosage of morphine fearing that it may actually "cause his death" and that Mr. Z could become "addicted to the medications." Mr. Z's primary nurse caregiver was uncomfortable with the physician's opinion and sought a palliative care consult to discuss pain management options.
Shortly after Mr. Z's pain was better controlled, he had a stroke that left him unconscious and he subsequently developed pneumonia and septicemia. When asked by the attending physician about the future course of treatment, the son, who was previously estranged from Mr. Z but was recently designated his durable power of attorney for health care, stated that he wanted "everything done to keep his father alive," including, if necessary, amputating the gangrenous leg with partial pelvic removal, starting mechanical ventilation, and inserting a feeding tube. The attending physician was dismayed and told the son that not only was this against his father's wishes but that she would not honor the son's request because it was "tantamount to torture." The son did not relent, however, and insisted that everything be done because the matter was "in God's hands" and that a "miracle could still happen. My father needs to be kept alive with everything so that God can perform a miracle. My father was faithful. God will rescue him." He also perceived that stopping treatment was against the teachings of the Catholic Church to which he belonged. Furthermore, he threatened to bring suit against the physician and the hospital if his request was not honored and suggested that the real reason the physician wanted to "kill his father" was racial bias. The physician, as well as the nursing staff, were highly stressed and exasperated. They fully believed that they were doing harm to Mr. Z. (Courtesy of Dr. Michael Panicola, SSM Health Care, St. Louis, Mo.).