Background Mary Evelyn Greene, who has memory impairment, lives in a private room at Shady Brook Skilled Nursing Facility located in a beautiful suburb of a major metropolitan city. She has resided at Shady Brook for the past 18 months. Before moving into Shady Brook, Mrs. Greene lived independently in her own home with assistance from a private-duty nursing assistant and a housekeeper. She and her husband had resided together in this home for more than 50 years. Mrs. Greene is 89 years old and suffers from several health problems associated with aging. Mrs. Greene has one son, David Greene. David has the power of attorney to handle his mother’s health care and other personal affairs. David works as a trial attorney in one of the city’s largest and most prestigious law firms. He owns a large home in an upscale neighborhood and works hard to put two of his children through college and another one through medical school. His home is about an hour’s drive from his workplace and about 20 minutes from Shady Brook. David’s wife Barbara has never been close to her mother-in-law and has not shown much interest in her care. Hence, caring for his mother has become a major responsibility for David, and he is having a difficult time dealing with her declining health and the onset of mild dementia. It is becoming increasingly more difficult for David to leave his law practice or the court room to deal with issues related to his mother. Mrs. Greene’s husband was a very successful land developer who left her with a substantial estate, which meets all of her financial needs. After her husband passed away, Mrs. Greene decided to remain in her home. She was able to maintain her independence until she was 87 years old, when she began to show signs of dementia. Shortly thereafter, David moved her to Shady Brook. David also hired a part-time “sitter” to keep her mother company because she was too weak to go out of her room on her own. Mrs. Greene seems to enjoy the sitter’s company and likes the attention she gets. Upon entering Shady Brook, Mrs. Greene became depressed over losing her independence and her home and felt a growing frustration with forgetfulness. She gradually lost her appetite, and her desire to eat continued to decline. On the other hand, Mrs. Greene seems to enjoy the smell of certain foods. The associates monitor and document her food intake and her facial expressions when she is offered different foods. Mrs. Greene is particularly fond of Susan Brown, a certified nursing assistant (CNA), who sits with her and helps Mrs. Greene with whatever little she can eat. When this occurs, her appetite shows some improvement. Mrs. Greene also responds well to volunteers who carry out activities at the facility. Frustrated Family Member Mrs. Greene has become too weak to eat on her own. When no one is feeding her, she leaves most of her food on the tray. Recently, she has sustained a weight loss of more than 5 pounds per week. Her plan of care needs to be reevaluated, and her situation needs immediate attention. David has been visiting his mother quite regularly. Recently, however, his visits have become less frequent, generally two to three times per week. The associates who work on Mrs. Greene’s nursing unit have reported some changes in David’s attitude. At one time he became angry with his mother, raised his voice, and spoke to her as if she were a bad child. Although no one was present in Mrs. Greene’s room at the time, the associates working at the nursing station heard David’s loud voice. When the charge nurse went into Mrs. Greene’s room to find out why David was angry, David told her that it was none of her business. On David’s subsequent visits, the associates observed that Mrs. Greene would become agitated during David’s visits. These issues were brought to the charge nurse’s attention, and they were documented in the patient’s medical record. The Dilemma One day David approached the charge nurse and exclaimed that his mother had expressed that she wished to die. On his next two visits, David also told the CNAs that his mother’s desire was not to eat anything so she could just die a quick death. This was the first time the CNAs had heard that Mrs. Greene had expressed a desire to die. The associates also believed that Mrs. Greene appeared to be happier when David was not there. Before the week was over, David came into the facility early in the morning on his way to work. He handed a sealed envelope to the incoming charge nurse on the day shift. The envelope was addressed to Betty Wright, Shady Brook’s administrator. David said to the charge nurse, “I have been telling you people that my mother wishes a speedy death. Tell your administrator that I will be filing a lawsuit if my mother’s wishes are not carried out.” David left without visiting his mother. Betty Wright decided to place the issue on the ethics committee’s agenda for that same afternoon. As a safeguard, Betty also notified the facility’s liability insurance carrier of the potential legal action. Meeting of the Ethics Committee That afternoon, Betty met with members of the ethics committee: chaplain, medical director, director of nursing, charge nurse, social worker, two CNAs, and the local ombudsman. Betty began the meeting with these remarks: “The man’s mother has been declining rapidly and eats very little. He wants his mother to die rather than prolong her suffering. I have learned that the son is the heir to his mother’s estate, and my overall concern is my trust in his decision or his motives. I think he needs the money to pay for the college expenses for his three children. Although it is not uncommon for some residents to be ignored by family after they are admitted, it is rare that they express the wish to enable the death of a relatively healthy person.” The ethics committee is faced with the issue of what is legally and ethically appropriate. The committee deliberates on whether or not to comply with David’s request to withhold food as well as the threat of a lawsuit.
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