HCA 415 Module 5 End-of-Life Decisions Example

What Matters Most Now: An End-of-Life Decision in Metastatic Lung Cancer

Student Name

Health Care Administration Program, Aspen University

HCA 415: Healthcare Ethics

Instructor Name

Month Day, Year

What Matters Most Now: An End-of-Life Decision in Metastatic Lung Cancer

End-of-life decisions test every ethical principle: respect for the patient's wishes, the duty to help and not harm, fairness and the roles of families. They also test institutions, which must support conversations that many clinicians avoid. The composite case examined here involves a man with advanced lung cancer whose family disagrees with his wishes.

The Case

Mr. N., 71, has metastatic lung cancer that has progressed after two lines of chemotherapy. He is short of breath, sleeps much of the day and has lost weight. His oncologist offers a third treatment with a small chance of slowing the cancer. Mr. N. has started saying he wants to go home. His wife and son want him to take every treatment. He has capacity. He has no written advance directive.

Goals of Care

The first ethical step is to learn what matters to Mr. N. A structured conversation explores his understanding, hopes, fears and trade-offs. The table summarizes the conversation.

The Right to Refuse

Any treatment, including one that sustains life, may be declined by a patient who can decide. In the Cruzan case the Supreme Court worked from the assumption that the Constitution shields a capable person's choice to decline treatment, while allowing a state to set a high evidence bar before surrogates may stop treatment for someone unable to speak (Cruzan v. Director, Missouri Department of Health, 1990). Mr. N. may decline further chemotherapy.

Withholding and Withdrawing

Ethics and law generally treat withholding a treatment and withdrawing one already started as morally equivalent. This matters because families sometimes fear that stopping a treatment is worse than never starting it. If Mr. N. later needs breathing support, the team can offer a time-limited trial with clear goals, stopping it if the goals are not met.

Palliative Care Is Not Giving Up

Palliative care focuses on symptoms, communication and support at any stage of serious illness. When newly diagnosed patients with metastatic lung cancer were randomized to add palliative care from the start, they reported higher quality of life, less depression and received less aggressive care near death, and they also lived longer, with median survival of 11.6 versus 8.9 months (Temel et al., 2010). Palliative care can accompany or replace disease treatment.

Hospice

Hospice provides comfort-focused care, usually at home, for people expected to live roughly half a year or less who decide to stop treatments aimed at the disease. For Mr. N., hospice could provide nursing visits, oxygen, medications for breathlessness and support for his family, making his wish to be home possible.

The Family's Perspective

Mr. N.'s wife and son are not ignoring his wishes; they are grieving and hoping. Ethically, their role is to support his choice while he can decide. The team met with the family and Mr. N. together, let him explain his wishes in his own words, and acknowledged the family's love and fear.

Planning for Loss of Capacity

Mr. N. may lose capacity as his illness progresses. The team helped him name his wife as health care agent and complete a portable medical order and advance directive stating his wishes. Advance directives matter: when older adults near death had written living wills asking for limited or comfort care, the care they received usually matched those wishes (Silveira et al., 2010).

The Principles Applied

Respect for autonomy supports honoring Mr. N.'s wish to go home. Beneficence, understood through his values, supports palliative and hospice care. Nonmaleficence warns against burdensome treatment with little expected benefit. Justice is served by giving him access to the full range of care, including palliative services, regardless of his choice.

The Decision

Mr. N. chose not to start the third treatment and to enroll in home hospice. His son asked whether he was giving up; Mr. N. said he was choosing how to spend his time. The team documented the conversation, his decision and his new orders. He spent his remaining weeks at home.

Institutional Responsibilities

Hospitals and practices support good end-of-life care by training clinicians in serious illness conversations, making palliative care consultation easy to request, ensuring advance directives are visible in the record and honoring portable orders across settings. Administrators can track how often goals-of-care conversations are documented.

Counterargument

Some argue that clinicians should always offer every treatment that might extend life. But offering a treatment is different from recommending it, and patients deserve an honest account of expected benefit and burden. Presenting palliative care as an equal option respects patients more than presenting it only when nothing else remains.

Cultural and Religious Views

Views about death, prognosis and family roles vary across cultures and faiths. The team asked Mr. N. and his family whether any beliefs should guide care at the end of life, and a chaplain met with them. Respecting these views is part of respecting the patient as a whole person.

Supporting the Team

Clinicians also feel moral distress when families press for treatments the team believes will not help. The oncology unit held a short debrief after Mr. N.'s discharge, and the palliative care team offered support. Caring for caregivers is an organizational responsibility.

Prognosis and Honesty

Families often ask how much time is left. Clinicians can offer honest ranges while acknowledging uncertainty, which helps families plan. Avoiding prognosis to protect hope often backfires, leaving families unprepared. Mr. N.'s oncologist gave a range of weeks to a few months and invited questions.

Conclusion

Mr. N.'s case shows that end-of-life ethics begins with learning what matters to the patient. His right to refuse treatment, the moral equivalence of withholding and withdrawing, and evidence that early palliative care improves quality of life support honoring his wish to be home. Supporting his family, planning for loss of capacity and documenting his wishes completed the ethical work.

References

Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990).

Silveira, M. J., Kim, S. Y. H., & Langa, K. M. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, 362(13), 1211-1218. https://doi.org/10.1056/NEJMsa0907901

Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., Dahlin, C. M., Blinderman, C. D., Jacobsen, J., Pirl, W. F., Billings, J. A., & Lynch, T. J. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine, 363(8), 733-742. https://doi.org/10.1056/NEJMoa1000678