-trf-
Thursday, 3 March 2011
Case 1
This is a case i saw today in the clinic. Therefore the information provided here is not that detail. However the issue that i want to bring it up is regarding ethical issue. Patient is a 63 year old female, known case of diabetes, hypertension, hyperthyroidism, mentally challenged secondary to childhood enchephalitis and also invasive ductal carcinoma of the left breast. Her reason for this clinic follow up is for her antihypertensive and also insulin therapy for hypertension and diabetes. Her hyperthyroidism is being treated with carbimazole. The important issue here is her invasive ductal carcinoma of left breast. The MO that i was tag to explain to the patient and also her son who came along regarding the her carcinoma and the risk of death if there is no treatment undergone. This is because the patient's family member's refuses to do the surgical management for the carcinoma and the patient is not mentally fit to decide for herself. Despite being advise by the surgical department, the family members still refuses to undergone the surgery. What could us as a health professional do in this kind of situation? From what i have gathered and also the opinion i sought from the MO and the specialist in the room, we need to respect patient's autonomy in which in this case patient is not mentally fit to decide for herself which ends up with her next of kin. We need to do our best to advise the family members and persuade them to undergone the surgery in view of her life threatening condition. Even if it fails, at least we have done our job as a doctor. However, there is still one thing in which we could do which are in the legal issue. We go over ride the decision of the family members in view of this kind of condition. It is being done in overseas but in Malaysia context, we are still bounded by social rules in which the family plays an important role despite having the legal method. Therefore, this kind of scenario is very hard to be dealt with. Is there any other ways that we could handle this? Give your thoughts if you do have any opinions in this. :)
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Controversial.
ReplyDeleteI see here a complex situation where a 63 year old woman who needs a full time caregiver has a breast cancer. Medically, the cancer can be treated by surgery but is there a guarantee of curing the breast cancer by surgery? Probably not. What surgery may do is to prolong life. The caregivers do not want surgery. Ru Fah feels that this decision by the caregivers should be overruled by legal means and surgery forced upon the patient. I disagree. Are you, as the doctor, prepared to do the surgery and continue to provide care for the patient after surgery without the present caregivers? I am sure you cannot. If you cannot step into the role of a caregiver, you can at least try not to destroy whatever peace the present caregivers have now. Death is not to be viewed as an enemy but as a natural exit point for this life on earth. There are things that we can do to prolong life and things that we can do to prolong suffering. As doctors we pray that we know the difference.
ReplyDeleteDr.Vela, I agree with your reasoning in this case.I would decide likewise as well.
ReplyDeleteHowever I feel Ru Fah's argument is one that is worth to be pondered. It might not be ethically correct in this case but what if the scenario was one that is a bit different ?
Say the patient is not able to make a sound judgement, and the intervention needed is one that will definitely save his/her life. And we are extremly sure that with our experience and current evidence , the intervention WILL provide a good outcome. However the family refuses this though counselled and discussed with thoroughly.
Are we in any capacity to involve the law to help save the patient's life?
If my argument is correct, I see a paradox of medical ethics here. Beneficence vs patient autonomy.
How does one approach this then ? Do we do all that we can to fight for the patient's life? or do we simply abide to the sacred values of medical ethics?
My choice would be to follow patient autonomy as that was instilled to me deeply since the very start of this education. But can we at least try or do we have any means to do so?
And since we are in this topic Dr, what if the ethical issue being involved was futility? Do we still try hard though we know there is no hope just because the family insists? What I encounter in our wards here seems not to be the case.
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ReplyDeleteFrom my point of view, patient autonomy comes before anything else. As a doctor, we can do our best to counsel but the final decision will be on the patient always. In the case of a mentally challenged pt, if he/ she is not capable of making a sound decision, I think the decision shall be discussed with the authorised caregiver. To prevent controversies, I think there is a law that sort of dictates who will be the authorized person to have some say. This is crucial as there are a lot of instances when family members have differing views and doctors got caught in between.
ReplyDeleteHaving said that, I think it is best to meet all the family members to discuss further plans.
I would say that we will accept the family members decision in this case.
I agree with Dr. Vela and Sundaresan, however i must say that i disagree with you first sentence Kah Weng as no one part of ethics is superior to the other and that patient autonomy cannot blindly always come first. For example, in a scenario of euthanasia, does patient autonomy always come first? I believe otherwise. Perhaps the rules of medical ethics are best reviewed patient by patient.
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