Modules

Cross-cultural communication

Conclusion

Interim history

Betsy does not enter the clinical trial but does agree to surgery and receives radiation treatment for her back. She is sent home on analgesics for her pain but she is not well enough to manage the restaurant and hires the son of a friend to help Dani.

Three months later

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

  • Dr. Harrell: Hello, I’m Dr. Harrell. I’m the division head of this service. I wanted to come to talk to you about your mother…

    Elsi: What are you doing here? I thought Dr. Tyson was taking care of our mom.

    Dr. Harrell: Well, what we do at this hospital is we rotate from one service to another, and Dr. Tyson went to another service last week.

    Elsi: Great…

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

    Elsi: What do you mean there’s nothing you can do? There must be something. There were talks of two experimental treatments just a couple of weeks ago.

    Mado: Elsi, we have to tell Maxon.

    Elsi: We can’t tell our brother.

    Mado: We have to…

    Elsi: If we tell Maxon, then mom will know it’s the end.

    Mado: It is the end, Elsi, face it… it is the end!

    Elsi: She doesn’t need to know…

    Mado: Elsi, let me tell mom.

    Elsi: No!

    Mado: (to Dr. Harrell) Look, we haven’t said anything to our mother, she doesn’t know. Dr. Tyson knows about our situation; if you speak to her, she’ll explain everything to you.

    Dr. Harrell: Your mother doesn’t know?

    Elsi: No, she doesn’t know.

    Dr. Harrell: She must know she is dying. Obviously, she’s been quite sick… She would want to know she’s dying… she would want to take care of her affairs…

    Mado: Well, she doesn’t know…

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

    Mado: 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…

    Elsi: We’d have to talk to our dad about that…  I’m sure he’d want you to do everything you can to help our mother.

    Dr. Harrell: By all means, please have him 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 her. If they think they’re only going to prolong her suffering, they won’t do it. So, what’s important now is that we control her pain and we keep her comfortable, okay?

    Elsi and Mado: Okay…

Conclusion

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

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 Exantus 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 start 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 Betsy’s chart and states that the physicians will not do anything that would “prolong her 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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