clkt Posted March 20, 2007 Report Share Posted March 20, 2007 You are taking care of an elderly patient who is essentially brain dead...but the family is refusing to accept this and demands that absolutely everything continue to be done for the patient...what would you do? What are your obligations to the family/patient/society? What if it were a child, would you do anything differently? Legally, are you allowed to take the patient off life support? Alternatively, if a patient is very sick, and drug 1 gives him x months, drug 2 costs 50,000 more but extends his life for 3 months more than drug 1, would you give him drug 2? If your answer is no, what would you say to the patient if he is aware of drug 2 and demands it? Link to comment Share on other sites More sharing options...
illusion Posted March 20, 2007 Report Share Posted March 20, 2007 isn't it an obligation to act in the best interests of the patients. If this ridiculously expensive drug is accessible (in that our canadian health system) has access to it then you should give the option to the patient. sometimes hospitals just don't have access to all the meds right? I mean some treatments are known to be futile and they're still administered because there is a small hope that they are effective or they improve the quality of life of a patient. ... and if not offered...then wouldn't you wonder about hospice and palliative care (indeed they take both human and material resources as well)? Link to comment Share on other sites More sharing options...
Curious P Posted March 20, 2007 Report Share Posted March 20, 2007 First, I'd check out the CMAJ's collection on bioethics for clinicians series, you'll find case studies covering many of the scenarios you listed: http://www.cmaj.ca/cgi/collection/bioethics_for_clinicians_series Personally, as an applicant, if I was posed any of the above questions I would want to address each of the following in my answer: -1- An evaluation of the patient's motives, position, and level of understanding of the situation. Does this patient (or their proxy decision makers) understand the medical situation, are they able to think rationally, etc. -2- Balancing of limited resources. As a physician, I would obviously act as an advocate for my patients and want to provide them with the resources and services necessary to improve their health. Faced with a limited supply of resources and time, I would base my decision on what I think would provide the greatest medical utility, and NOT on on cost. If a particular drug has been approved for use, and I believe it to be superior to all alternative medications, than I would not hesitate in prescribing it. -3- Alternative approaches/support services. If I felt that a patient or their family could benefit from outside counseling, or alternative solutions, than I would discuss these options with them, and perhaps bring in an expert that has greater experience dealing with the particular dilemma I’m faced with. If I didn’t feel comfortable providing advice/service, then I would explain the reasons for my reservations and refer the patient to another clinician. Hope this helps! Link to comment Share on other sites More sharing options...
Smurfette Posted March 20, 2007 Report Share Posted March 20, 2007 Alternatively, if a patient is very sick, and drug 1 gives him x months, drug 2 costs 50,000 more but extends his life for 3 months more than drug 1, would you give him drug 2? If your answer is no, what would you say to the patient if he is aware of drug 2 and demands it? Drug 2 might prolong life, but if the patient is *very* sick, then it may not allow him/her to have a very good quality of life. I would be willing to prescribe it (despite the higher cost) if I thought it were better, but if that's an issue I would explain it to the patient. Link to comment Share on other sites More sharing options...
eise Posted March 20, 2007 Report Share Posted March 20, 2007 A fellow poster shared a real-life example similar to your second scenario. An elderly man is dying (i think from cancer?) and breaks his arm (i'm screwing up the story but you get the point). The surgeons refuse to operate on the arm because he will be dead in 3 months even though he is in excrutiating pain. This man dies within the month. The resources would be 'wasted' since this man would only benefit from 3 months of their use. However, is it ethical to refuse a man treatment and, ultimately, improved quality of life because he has a shorter life span? I am not sure. anyone have any thoughts? Link to comment Share on other sites More sharing options...
Jochi1543 Posted March 20, 2007 Report Share Posted March 20, 2007 When my greatgrandmother had stomach cancer and needed to have her stomach removed, we had a VERY hard time finding a doctor in our Russian (free) healthcare system who'd agree to operate on her. While the risk of death was an issue (10% at her age, 75 or so at the time), the main issue was doctors not wanting to bother with an elderly woman. The surgeon gave her 3 years to live... It's been 15. Link to comment Share on other sites More sharing options...
illusion Posted March 20, 2007 Report Share Posted March 20, 2007 A fellow poster shared a real-life example similar to your second scenario. An elderly man is dying (i think from cancer?) and breaks his arm (i'm screwing up the story but you get the point). The surgeons refuse to operate on the arm because he will be dead in 3 months even though he is in excrutiating pain. This man dies within the month. The resources would be 'wasted' since this man would only benefit from 3 months of their use. However, is it ethical to refuse a man treatment and, ultimately, improved quality of life because he has a shorter life span? I am not sure. anyone have any thoughts? Actually, you're probably right. I know multiple myeloma is characterized by bone fractures (bc of factors that stimulate osteoclast activity) and sadly often how it's diagnosed. In this case I think it's really important to offer the option of the procedure to improve the quality of life. I mean the patient may not want it because of having to undergo additional procedures and possibility of more complications. but I wonder if we were to restrict resources to those who will only survive...that might bring up more questions on what exactly is ethical (eg. physician-assisted suicide)? although indeed these are some tough questions to ponder over Link to comment Share on other sites More sharing options...
clkt Posted March 21, 2007 Author Report Share Posted March 21, 2007 so, legally, are you allowed to take a brain-dead patient off life-support? And would you do it? Link to comment Share on other sites More sharing options...
Curious P Posted March 21, 2007 Report Share Posted March 21, 2007 I don't know the legalities surrounding brain-dead patients. If however, I had a patient in a persistent vegitative state I would not unilaterally decide to withold treatment (doing so can lead you into trouble). I believe physicians have an obligation to respect the wishes of the patient/family, and it would be my duty to try and understand the motives of the patient/family and see if I can come to some sort of compromise (perhaps moving the patient to a long term care facility, or some form of in-home care). Link to comment Share on other sites More sharing options...
Sharpie* Posted March 21, 2007 Report Share Posted March 21, 2007 Are we saying the patient in the first question is essentially brain dead? Or definitely brain dead? I believe that if the patient is definitely brain dead and has no chance of recovery, they are not technically considered "alive" and should be taken off of life sustaining care. Keeping a brain-dead patient on life support puts undue strain on resources--it is unfair to other patients who need the life-sustaining care and have a chance of survival. I would explain this very sympathetically to the family; I would probably involve other members of the health care team such as psychologists, if they are having considerable trouble coming to terms with the death. It's a tough situation, but I think in the end you're really just prolonging inevitable death with no real benefit to the patient. Link to comment Share on other sites More sharing options...
agregson Posted March 21, 2007 Report Share Posted March 21, 2007 To declare a patient brain dead you need 2 physicians to agree. There is a series of tests of brainstem function that are done to ensure that there is no brainstem activity. Then after discussing with family what this all means, you can take the patient off ventilators/pressors etc. If you are faced with an extremely difficult situation most major hospitals have clinical ethicists/ethics panels who can help. Link to comment Share on other sites More sharing options...
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