A CASE STUDY: Annie's Story (Angelique Flowers)

For my case study, I used a real life story taken from headlines. It is Angelique Flower's story. I have given her the nickname "Annie." A summary of the case study is below, but I invite you to hear her story first person by watching the video. It is easier to make determinations about ethics and law when we do not know the person, but our opinions might change when we have personal knowledge. As nurses our care is personal, so I believe Annie's video helps bring that to light more effectively than words on a paper.

Karen is a fictional character inserted into Annie's story to illustrate the ethical, legal, and moral implications for nurses that could possibly be involved in this or similar stories. I have also transported Annie to California from Australia so I could discuss the legal issues in the state where I live.

CASE STUDY:

Annie is a 31 year-old woman living in California who is admitted to hospice care after a 16 year long battle against Crohn’s disease and recent diagnosis of stage IV aggressive colon cancer that has metastasized to her liver, abdominal aorta, lymph nodes, uterus and ovary. Chemotherapy has been ineffective. Despite stents placed in her colon, she continues to suffer from the effects of a total bowel obstruction resulting from a large tumor. Annie has declined the risky surgery to remove this obstruction because it would require her last days to be spent in even more pain during recovery. Currently, she is experiencing excruciating abdominal swelling, pain and vomiting of fecal matter which leaves her incapacitated. She is also at risk for peritonitis if the tumor were to burst. Large doses of fentanyl have been unsuccessful in controlling her pain and anti-nausea medications are not working. Her doctors have given her only months to survive. Annie has already signed a DNR order and is an outspoken proponent for euthanasia.

As part of Annie’s interdisciplinary healthcare team at hospice, a palliative care nurse practitioner, Karen, is concerned about her own legal and ethical responsibilities in this situation. Palliative sedation appears to be a viable option for Annie as she meets the criterion: imminent death, previous attempts at palliative treatments have not brought desired relief, DNR orders are in place, a desire exists to relieve suffering, and palliative specialists believe Annie’s condition warrants the treatment (Marshall, 2009). Because of Annie’s appeal for euthanasia, Karen wonders if palliative sedation could be seen as a substitute for physician-assisted suicide or euthanasia, both of which are illegal where she practices. Karen’s questions about this are not unfounded. Thulesius, Scott, Helgesson & Lynoe (2013) point out that there is conceptual confusion when speaking of death and dying, in that people usually do not readily distinguish between differing actions such as euthanasia, physician-assisted suicide, palliative sedation, or withdrawal of life sustaining treatments. Furthermore, Hahn (2012) reports that there is currently very little research or even any standard definition to adequately distinguish palliative sedation from other end of life managements. Karen worries that she could be pulled into legal troubles if she offers information about or assists in the act of palliative sedation in Annie’s care.