Mr. Karl, an otherwise healthy 62-year old man, arrived at Hapless Hospital emergency room by ambulance.He had serious stab wounds to his chest and back, and he was loosing blood quickly.The emergency technician on the ambulance explained to the emergency room physician that he was called to Howdy Podner Bar by the owner, who telephoned to report a fight and request an ambulance.He said that Mr. Karl complained that he had been knifed by his son and that Mr. Karl was uncooperative but too weak to successfully oppose ambulance attendants on the four block drive to the hospital.Mr. Karl's wife, who was called by another patron at the bar, arrived at the emergency room at the same time as Mr. Karl.

When an emergency room physician explained to Mr. Karl that he required several units of blood, Mr. Karl absolutely refused to accept that form of treatment.He said that he understood the consequences of not receiving blood under the circumstancesthat death would be likely, if not inevitable.However, he explained that his Jehovah's Witness faith did not allow him to consent to a blood transfusion.In any case, he explained, religion or not, he "had his own reasons" for not wanting to survive this stabbing, and he did not want any blood.His wife, who is also a Jehovah's Witness, begged the doctor to provide the blood and save her husband's life.She explained that her husband was misinterpreting Jehovah Witness doctrine, which permitted a blood transfusion in certain circumstances.In fact, she argued, their faith does not provide that he not be given blood; it merely requires that he not actively give his consent to receiving blood.She pointed out that they had been married for 35 years and that she knew he wanted the transfusion, but he felt obligated by his religion to appear to oppose it.Physicians treated his wounds but did not provide any blood.

Mr. Karl was maintained in the emergency room.He continued to object to any form of blood transfusion, but after several hours of blood loss became less coherent.He began to cry about the guilt he suffered from stabbing his son, and he began talking about the Lord's revenge upon evil men.When he was approached by physicians, he merely screamed obscenities as loudly and raucously as his weakened condition would permit.

About 10 hours after he arrived at the emergency room, Mr. Karl was afflicted with an apparent stroke and slipped into unconsciousness.He then was moved to the intensive care unit.He lost breathing capacity and he was placed on a respirator by the ICU physician.Shortly after his move, his three daughters arrived, confirmed what their mother had said earlier and begged that their father be given all available treatment, including blood.His only son, with whom he had been fighting earlier in the evening, was arrested and remained in jail.

Within the next several hours all bleeding ceased, and he remained in stable condition.Given the consequences of the stroke, his physicians concluded that there was virtually no hope that Mr. Karl would regain any cognitive abilities.Intravenous nutrition supplementation was commenced, then replaced by a naso-gastric tube through which nutrition was passed directly to his stomach.

After her father had spent two weeks in intensive care, one of the daughters requested that her father's respirator be removed.The doctors explained that they had several options.The respirator could be removed at once, which would surely lead to her father's death.He could be "weaned" from the respirator, with respirator support removed slowly (and reinstated when necessary), a process which would not result in his immediate death, but would likely shorten his life substantially.He could be "terminally weaned," which would be the same as the weaning process except that the support would not be reinstated, even if it were necessary.Finally, he could be maintained on the respirator.Mr. Karl's wife and daughters determined that he should be removed from the respirator in whatever manner the physician thought proper, and he was successfully "weaned" from it.A week later, Mr. Karl's wife asked that his feeding tube be removed.She said "He always said that the worst thing that could happen to him was to be a vegetable."In addition, his family physician reported that he had once talked to Mr. Karl about living wills and that Mr. Karl had asked for a living will form, although he had not filled it out.Two of the three daughters agreed with their mother that the feeding tube should be removed, but one strongly objected, saying that she believed it would be wrong, from a moral and religious point of view, to do so.

Mr. Karl's wife and children are his only heirs.He has always been particularly close to the daughter who does not want his feeding tube removed.His family physician reports that during a previous hospitalization for an ulcer, Mr. Karl depended heavily upon his wife, to whom he has been happily married for 35 years, and left every treatment decision to her.The current medical and hospital charges of about $5,000 a day are paid by Mr. Karl's insurance (80%) and his family (20% coinsurance obligation).The family resources will be exhausted in another few weeks when the maximum annual payout on the insurance policy will have been met.After that, his health care will be paid by Medicaid.

What treatment would have been appropriate at each point in Mr. Karl's hospitalization?How should that have been decided?What judicial consequences could (or should) each medical decision have?Would you answer differently if you were Mr. Karl?A member of Mr. Karl's family?One of his creditors?The hospital administrator? The doctor?The hospit