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• W332686159 abstract "Mr. R is a fifty-year-old man with AIDS who was admitted by Dr. G to a major medical center three months ago with deteriorating mental status. Mr. R has experienced several opportunistic infections since his AIDS diagnosis two years ago, including Pneumocystis carinii pneumonia and cytomegalovirus (CMV) retinitis. Approximately one month after admission Mr. R was diagnosed with CMV ventriculitis--an end-stage, terminal infection of the brain. In general, CMV ventriculitis has an extremely poor prognosis, with life expectancy measured in weeks. Mr. R's mental status had deteriorated further since admission, and he had only brief moments of consciousness. Both his parents and the medical staff agreed that he was incompetent to make treatment decisions. Dr. G asked Mr. R's parents to decide whether to begin aggressive treatment of the ventriculitis requiring intravenous infusions, or to initiate comfort care. Mr. and Mrs. R were told that treatment might prolong Mr. R's life for a limited amount of time, but that the chances of this were very poor. Treatment required lengthy daily infusions that had significant side effects and would make it impossible to transfer Mr. R to a hospice. It was not clear whether Mr. R was suffering physically. A year ago, during an episode of AIDS-related pneumonia, Dr. G had told the Rs their son would die, but Mr. R had subsequently made a complete recovery. Dr. G also knew that Mr. R had a life insurance policy that would mature to $700,000 dollars if Mr. R lived for another four months, but would be worth $200,000 if Mr. R died before that time. Both Mr. R and his parents spoke openly about the life insurance policy to the medical staff. Mr. R had previously expressed his strong desire that his family, especially his nephews and nieces (Mr. R had no children of his own), inherit the larger amount of money. On several occasions when he was competent, Mr. R had clearly expressed this desire to numerous people, including his parents, his primary care provider, Dr. G, and the medical staff. In all respects Mr. R and his parents appeared to be a close and loving family confronted with a very difficult situation. Dr. G recommended that comfort care be initiated because he felt there would be no clinical benefit to Mr. R in doing more than this. Given the prior incident in which Mr. R recovered against his prediction, however, Dr. G was comfortable in treating the ventriculitis aggressively for a two-week period in order to assure Mr. R's parents that treatment would not help Mr. R recover. Mr. R's parents chose to follow this course, and as Dr. G predicted, after the completion of the second week of therapy, Mr. R's condition had deteriorated. Dr. G again recommended that treatment be discontinued and comfort care initiated, explaining that in his clinical judgment there was no chance that Mr. R would live another four months regardless of treatment. Although he did not inform the Rs, Dr. G felt he could not ethically continue treatment of Mr. R since treatment was futile and would not be in Mr. R's best interests. He felt the parents' decision might be influenced by the insurance money, and by unrealistic expectations regarding their son's prognosis. Dr. G planned to transfer the care of Mr. R to another physician if Mr. R's parents decided to continue therapy. Can a monetary incentive to prolong life ever play a valid role in treatment decisions? Should Dr. G take the monetary incentive into account in advising Mr. R's parents of the appropriate course of treatment? COMMENTARY by Melinda Friend Mr. R's wish for his family to inherit the maximum proceeds from his life insurance policy was a rational and autonomous desire. No one has the right to claim that his or her understanding of the proper factors to consider in prolonging Mr. R's life takes precedence over those factors Mr. R identifies as important. It is Mr. R's life: if he were competent and demanded treatment he would legally be entitled to it. …" @default.
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• W332686159 date "1995-07-01" @default.
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• W332686159 title "For love or money." @default.
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