Gilgunn-Massachusetts General Hospital

In mid May of 1989, Catherine Gilgunn, a 71 year-old resident of Charlestown, Massachusetts, fell in her home and injured her left hip. She had been hospitalized three times before to repair a broken hip, and was reluctant to go to the hospital one more time. She had been in generally poor health for many years, with diabetes, heart disease, and chronic urinary tract infections. She was recently diagnosed with Parkinson’s disease, and also recently received a mastectomy for breast cancer. Moreover, she had suffered a stroke the year before, from which she never fully recovered.

Catherine’s 30 year-old daughter Joan, her primary caregiver, allowed her mother to delay going to the doctor for several weeks. Medical complications secondary to diabetes began appearing. Joan took her mother to Massachusetts General Hospital (MGH) on June 7, 1989. Nine days later, before surgery could be performed, Catherine suffered two grand mal seizures, followed by repeat seizures that could not be controlled until June 29^th. Before the seizures could be brought under control, she suffered extensive brain damage, resulting in a coma. Joan, who was the surrogate, informed the physicians (with the approval of Mr. Gilgunn and the other five children) that Catherine always said she "wanted everything done" that was medically possible. With the encouragement of the hospital’s Optimum Care Committee (OCC), Mrs. Gilgunn’s attending physician wrote a DNR order on July 5^th, despite these expressed wishes. Dr. Ned Cassem, the Chair of that committee and acting as the consultant, took the view that the family’s opinion was not relevant, since CPR was not a "genuine therapeutic option." The social worker notes concurred that the family’s inability to prepare for the inevitable did not "justify mistreating the patient." Because of his inability to argue strongly on medical grounds against Joan and her family’s beliefs, the doctor revoked the DNR order two days later.

The following month a new attending physician, Dr. William Dec, took over the case. The new attending physician couldn’t convince Joan of the inappropriateness of CPR for her mother. Dr. Dec asked the OCC to review the case again. Dr. Cassem, still acting as a consultant on behalf of the committee, once again endorsed a DNR order because CPR would be "medically contraindicated, inhumane, and unethical." Dr. Dec, with the approval of the MGH legal counsel, wrote the DNR order. He also began to wean Catherine from the ventilator, since he regarded her as imminently dying. Her blood gases were not monitored during the weaning, because Dr. Dec did not expect her to survive on her own. Three days later, on August 10, 1989, Catherine Gilgunn died.

Joan Gilgunn sued the physicians and the hospital, alleging neglect and infliction of emotional distress. On April 21,1995, the jury returned a verdict in favor of the physicians and the hospital. They stated that although Catherine Gilgunn would have chosen to be resuscitated, such resuscitation would have been medically futile. Alexander Morgan Capron, an attorney-ethicist at UCLA, in writing his analysis of the case, points out that the American Thoracic Society position paper on life-sustaining therapy holds that life support "can be limited without the consent of the patient or surrogate when the intervention is judged to be futile." The paper defined "futile" as an intervention

that would be highly unlikely to result in a meaningful survival for the patient…Survival in a state of permanent loss of consciousness…may be generally regarded as having no value for such a patient.

In contrast to this typical approach in the literature, following the judge’s instructions, the jury found that the care withheld from Catherine Gilgunn was futile simply because it would not provide a cure. They never addressed the issue of "meaningful existence." Hence, for Capron, the case gets us no further

in developing public policy on the acceptability of physicians’ following counsel of the type offered by the Thoracic society--namely, that they are entitled to withhold care that does not offer sufficient likelihood of producing a "meaningful" existence for their patient.

Capron noted further that, because the plaintiff’s case was based on the claim that the defendant’s conduct had negligently inflicted emotional suffering on Joan (not Catherine), the real issue in the case did not get addressed, namely:

That the hospital at the time lacked adequate procedures to resolve the dispute between the family and the physician in an appropriate fashion and to maintain the treatment modality preferred by the patient until the issue was resolved.

[Sources: Capron, AM, "Abandoning a Waning Life," Hastings Center Report, 25, 4 (1995): 24-26. Gina Kolata, "Court Ruling Limits Rights of Patients," New York Times, April 22, 1995, 6. American thoracic Society, "Withholding and Withdrawing Life-Sustaining Therapy, Annals of Internal Medicine 115 (1991): 478-85. Kevin O’Rourke, Healthcare Ethics USA, 3 (1995): 6-7.]

Principles & Concepts: human dignity, autonomy, proportionate/ disproportionate means, futility, nonmalificence, best interests.

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