1. 1 CASES FINDING THE KEY

2. 2 HOWARD RUSSELL I [DETERMINING FUTILITY] Howard Russell is 34 years old and was diagnosed with AIDS when he became symptomatic in 1993. Ordinarily persons with AIDS will live about 21 months after they become symptomatic if they do not respond to the protease inhibitors. Mr. Russell has not responded to the protease inhibitors but has still lived 30 months. However, he is nearing the end. He is in the hospital and suffering from another infection and poor nutrition. He is being given antibiotics which are temporarily controlling the infection and he is being tube fed. IS MR. RUSSELL TERMINALLY ILL? IF HE IS TERMINALLY ILL WHAT QUESTIONS SHOULD BE ASKED ABOUT TREATMENTS THAT MIGHT BE CONSIDERED FOR HIM? HOW WOULD YOU ASSESS MR. RUSSELL’S QUALITY OF LIFE?

3. 3 HOWARD RUSSELL II The prognosis is that he will not leave the hospital, the tube feedings will have to continue, the antibiotics will be useful for only a limited time, and there is a good chance that he will experience cardiac arrest in a short period of time. IS THIS PROGNOSIS A GOOD REASON TO STOP ALL TREATMENTS? SHOULD THE THREATMENTS THAT HAVE BEEN BEGUN CONTINUE SINCE THEY ARE FUTILE? SHOULD ANY NEW TREATMENTS BE INITIATED?

4. 4 HOWARD RUSSELL III Upon admission, Mr. Russell agreed to a DNR order but after one week, he requested that the DNR order be reversed and that he be made a full code. There is no question about his decisional capacity. WOULD RESUSCITATION BE FUTILE FOR HIM? SHOULD MR. RUSSELL BE ALLOWED TO CHANGE HIS MIND? WHAT SHOULD BE THE CLINICAL RESPONSE TO THIS CHANGE OF MIND?

5. 5 HOWARD RUSSELL IV His physician and the medical staff think that a full code is inappropriate because of his failing condition. Their assessment is that, even if he were to survive the code, he would end his few remaining days on a ventilator. They admit that there is some chance that Mr. Russell might regain consciousness after being resuscitated even though he would be on a ventilator. WHY DOES HIS PHYSICIAN THINK THAT THE FULL CODE IS INAPPROPRIATE? WOULD CPR COUNT AS A FUTILE TREATMENT? IF CPR IS FUTILE, WHAT ABOUT THE OTHER TREATMENTS? ARE THEY FUTILE AS WELL? SHOULD THE PHYSICIAN’S JUDGMENT OVERRIDE MR. RUSSELL’S CHANGE OF MIND?

6. 6 HOWARD RUSSELL V Mr. Russell insists on resuscitation efforts partly because he wants to see his brother who is coming into town from Montana and partly because he simply does not want to surrender to AIDS. IS WANTING TO SEE HIS BROTHER SUFFICIENT REASON TO OVERRIDE THE FUTILITY DECISION OF THE PHYSICIANS? IS WANTING NOT TO SURRENDER TO AIDS SUFFICIENT REASON TO OVERRIDE THE FUTILITY DECISION OF THE PHYSICIANS? IS THERE A WAY THAT MR. RUSSELL AND HIS PHYSICIANS CAN COME TO SOME NEGOTIATED AGREEMENT? WHAT DO YOU THINK THE TERMS OF THAT AGREEMENT SHOULD BE?