Ms C, a 22-year-old woman from Guatemala who spoke only Spanish, initially presented in December 2006, during her 34th week of pregnancy, with marked leukocytosis and was diagnosed with acute myelogenous leukemia (AML). After delivering a healthy full-term daughter, she achieved remission with chemotherapy. However, 6 months later, a repeat bone marrow biopsy revealed relapsed AML. Ms C was transferred to a university hospital in June 2007 where she was treated with a second round of chemotherapy. In July, a bone marrow biopsy showed persistent AML. In discussions with Ms C and her partner, Mr M (the baby's father), the attending oncologist stated that there were no further curative treatment options.
Ms C was the oldest of many siblings, all of whom lived in rural Guatemala. Prior to her hospitalization, the patient lived with her 8-month-old daughter, Mr M, and his family. Ms C and Mr M were evangelical Christians and were undocumented immigrants. Mr M worked as a delivery person from 4 AM to 1 PM, then took over childcare duties while Ms C worked as a cook. Ms C was often deferential to her partner, allowing him to make medical decisions for her, although she had not officially designated him (or anyone else) as her health care proxy. Despite intensive efforts by the hospital social workers, it was not possible to obtain emergency visas for family in Guatemala to visit Ms C.
On July 30, 2007, after private conversations with the oncology team, the patient agreed to a “DNR/DNI” order. At the time of the Palliative Care Service (PCS) consultation on July 31, 2007, the patient had been in respiratory distress for several days but was still able to discuss goals of care and make medical decisions. Discussion with the PCS in Spanish clarified that Ms C's primary goal was to spend as much time as possible with her daughter in her remaining weeks, which would not be feasible were she transferred to the ICU. Mr M, however, requested that “everything be done,” saying, “we continue to hope and pray for a miracle.” In subsequent meetings, the PCS consultants reinforced the oncologist's assessment that curative options had been exhausted and encouraged her partner to begin his goodbyes. The PCS team was less and less able to engage Ms C in discussions due to somnolence, and Mr M wished only to discuss further curative treatment options and declined to consider discussions about end-of-life care plans. Mr M adamantly maintained that there was still hope for her recovery and continued to inquire about therapeutic options such as “surgery for her lungs” and “washing her blood.”
Despite supplemental oxygen and escalating doses of morphine and lorazepam, the patient's dyspnea worsened. On August 6, 2007, at 2:15 AM, a nurse noted that the patient had stopped breathing. When the oncology team arrived to pronounce her dead, they found Mr M trying to revive her by performing mouth-to-mouth resuscitation.
The palliative care attending, the medical student, the social worker, and the chaplain were interviewed by a Perspectives editor in January, 2008, 5 months after the patient's death.