AJ is a 59-year-old male with a history of poorly controlled diabetes mellitus (type 2), cardiovascular disease, multiple strokes, and end-stage renal failure (dialysis dependent). Patient states he was previously very active, but after his stroke he has been cared for in an intermediate care facility. His course has been complicated by multiple decubitus ulcers, immobility, aspiration pneumonia, and urinary tract infections, resulting in multiple hospital admissions. On this admission, AJ was diagnosed with vancomycin-resistant enterococcal sepsis. When transport arrived to take him to dialysis, he refused, stating "I no longer want to live like this." The attending physician consulted psychiatry who diagnosed major depression and felt patient did not have the capacity to make the decision to withhold treatment. The nephrology team refused to dialyze the patient "against his will." Palliative medicine was consulted to determine surrogacy and to evaluate capacity. AJ expressed understanding of his situation and the consequences of his action stating "I don't want to kill myself, but if I stop dialysis I'll die and that is my wish." AJ also stated "who wouldn't be depressed in my situation?" AJ has no identified surrogate, being estranged from his spouse who was reportedly abusive, and lacked other relatives or friends. The attending physician was assigned surrogate and immediately ordered an ethics consult.

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JD is a 48-year-old male patient of the outpatient cancer center affiliated with the local not-for-profit hospital-based health system. He has hemophilia A (congenital Factor VIII deficiency) and was started on an a recombinant DNAderived, antihemophilic factor for on-demand treatment and control of bleeding episodes and routine prophylaxis to reduce the frequency of bleeding episodes. JD has no insurance and was given several doses of medication after he told the cancer center that he had government insurance but lost his card. Routine investigation showed JD had no insurance. He admitted prevarication, stating "I was afraid you wouldn't treat me." Over the next several months, JD, who has a history of intravenous (IV) drug abuse, refused to allow social work to help him apply for financial assistance. He refused to sign Medicaid applications and would not produce the documents required to qualify for free care from the health system. In addition, he missed several appointments and became known for showing up at the cancer center at random times demanding treatment and being disruptive in the waiting room. He missed 90% of his follow-up appointments. A social worker on multiple occasions sat down with him to complete his paper work, but he either refused to cooperate or left the center in anger. One of the hematologists wants to refuse treatment due to the cost (over US$17 000/month) and JD's refusal to fill out financial aid forms. The other hematologist in the clinic has resisted dismissal, stating that it is their duty to treat this patient on his terms. The practice administrator requests an ethics consultation to resolve this dilemma.