Modules

Cross-cultural communication

Conclusion

Interim history

Panos does not enter the clinical trial but does agree to surgery and receives radiation treatment for his back. He is sent home on analgesics for his pain but he is not well enough to manage the restaurant and hires the son of a friend to help Sophia.

Three months later

Panos has increasing back and pelvic pain. He becomes weaker, is nauseous and vomits and is somewhat confused. He is readmitted. The teams of residents have changed on the ward and there is another resident assigned to Panos’ case. He speaks to Niki and Maria.

The medical staff agrees not to write a do not resuscitate (DNR) order on Panos’ chart until Kostas can arrive to say goodbye to his father. Panos dies peacefully one week later, never having spoken of his illness with his family.

  • Dr. Harrell: Hello, I’m Dr. Harrell. I’m the senior resident on this ward. Nice to meet you. Um, I wanted to come and talk to you about your father …

    Niki: Well, why are you here? I mean, Dr. Tyson is the one taking care of our dad.

    Dr. Harrell: Oh, well, what we do at this hospital is we rotate from one service to another. Dr. Tyson went to another service two weeks ago.

    Niki: Oh great …

    Dr. Harrell: Anyway, I’ve read your father’s chart, and examined him myself, and I’m afraid the news isn’t good. Your father’s cancer has spread. There is really not a lot we can do for him right now except keep him comfortable.

    Niki: What do you mean there’s not a lot? … I mean, there must be something you can do. There were two experimental treatments they were talking about just a couple of weeks ago.

    Maria: Niki, we have to tell Kostas. We have to call our brother.

    Niki: We can’t tell Kostas …

    Maria: We have to …

    Niki: If we tell him, dad’s gonna know it’s the end.

    Maria: It is the end, Niki, face it … it is the end!

    Dr. Harrell: Okay, let’s try and …

    Niki: He doesn’t know …

    Maria: Niki, let me tell him. (to Dr. Harrell) Look, Dr. Tyson knows, if you speak to her, she’ll explain everything to you. We haven’t said anything to our father, he doesn’t know.

    Dr. Harrell: He doesn’t know?

    Maria: No.

    Niki: No, he doesn’t know.

    Dr. Harrell: He must know he is dying. Obviously he’s been quite sick … I mean, he wants to know he’s dying … he’d want to take care of his affairs …

    Maria: No, no, no, he doesn’t know …

    Dr. Harrell: There is another thing I need to tell you. Um, in this situation, anything can happen, and so what we want to do is place what’s called a DNR order on his chart. Now what that means …

    Maria: Oh, I know, I know what it means, I’ve seen it on TV all the time. It’s where they don’t pound on their chest … they just let them go …

    Niki: Well, we have to talk to mom about that … I mean I’m sure she’s going to want the doctors to do anything you can for him.

    Dr. Harrell: By all means, please have her come in to speak with us about it, but I want to tell you, that the doctors won’t do anything that they think won’t help him. If they think it’s just going to prolong his death, they won’t do it. So, what’s important now is that we control his pain and we keep him comfortable, okay?

    Niki and Maria: Okay … thank you …

Reflection-on-practice

Do not resuscitate, medical futility and limits to treatment

There are no quizzes in this exercise. You are asked to think about the topic in the light of the case of the Kostopoulos family and the suggested literature. Try to put yourself in the place of the physicians involved in the cases. Write down the following:

  • Who are the stakeholders who need to be consulted or considered in your decision?
  • What information from each would you like to have?
  • If you had to explain your reasoning to an ethics committee, what arguments would you present?

Decision-making around the end of life is one of the most frequent and visible ethical dilemmas that health care workers face. Can patients or their families demand that everything possible be done? Must physicians accede to such requests if they disagree? On the other hand, can physicians or hospitals impose DNR or withdrawal of life-sustaining treatment?

How does this help us? We are not obliged to accede to such requests, indicating that we have some professional discretion in making a decision. But what information are we to use? What constitutes “benefit,” and to whom? How much benefit, or lack thereof, is contained in “almost certainly will not”? A 10 per cent probability, a 1 per cent, a 0.01 per cent? And is it our values and opinion as professionals that should take precedence or those of the patient and/or surrogate?

Consider the following scenarios and decide what you would do using the information and arguments you have written down:

  • An 85 year old man with chronic obstructive pulmonary disease and dementia, who resides in a nursing home, collapses while at lunch. The nursing home staff starts cardiopulmonary resuscitation (CPR) and call an ambulance. CPR continues for the 15 minutes it takes to arrive at the emergency room. Does the emergency room staff continue the CPR? Why or why not?
  • A 32 year old mother of three is burned in a house fire and is admitted to the burn unit with third degree burns over 80 per cent of her body. The unit staff knows that probability of survival in such cases is less than 10 per cent, and with considerable suffering. They have a policy to palliate such patients with pain medication until “inevitable” death. Is this policy a) morally, b) legally defensible?
  • Dr. Harrell says that a DNR order will be placed on Panos’ chart and states that the physicians will not do anything that would “prolong his death.” Is this an acceptable course of action, either morally or legally?
  • A comatose patient with multi-organ failure has been in the intensive care unit on life support for two months, and the staff feels that there is no chance of recovery. The family refuses to agree to withdrawal of life support, citing religious beliefs. After protracted discussions with the family, the hospital seeks a court order allowing them to terminate treatment. Is this an acceptable course of action? Is there a difference between withholding and withdrawing treatment?

In thinking about these issues, consider the policy guidelines for end of life care and DNR in your province or territory. If you are working in a hospital, does it have guidelines? This article will help in formulating your reasoning: “When is medical treatment futile?” by D.L. Kasman.


 

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