CEP Session Consent & Decision Making by Dr. Lee See Muah & Maleena Suppiah
6
th Feb 2015 FRIDAY
from 12pm to 3pm
Welcome to a learning session on Ethics & the Law. Below is a video combining the topics of Consent & Disclosure. Please click below to watch the 9-minute video. The learning objectives are clearly stated & the concepts & illustrations will help you in the case study discussions that follow.
Play Video
Case 1 Mdm. Chandran is 85 year old. She is on follow-up at your clinic for Type 2 diabetes mellitus, hypertension and dyslipidemia for the past 4 years. She has some anxiety and depression that has been successfully treated with a small dose of escitalopram. She is stable, her glucose is well controlled and she cooperates well with treatment and advice. She has been widowed for many years now. Her only son passed away twenty years ago. She is estranged from her daughter-in-law. Her siblings have been close and supportive. She is often accompanied by her brother, Mr. Sundram, to her hospital appointments. She is now a regular at your clinic. She has become very worried and concerned because she has been unable to contact one of her brothers, Mr. Vasu. Mrs. Vasu has severely restricted all contact between her husband and his siblings. A nephew has tried getting in touch to no avail. Mdm. Chandran has willed her only substantial asset, her HDB flat, to her niece, Mr. Vasu’s daughter. Mdm. Chandran wishes to change the beneficiary in her will, but all pertinent documents are in Mrs Sundram’s possession. Mdm. Chandran’s lawyer has instructed her to obtain a letter of fitness from her attending physician, you, that certifies she is of sound mind. There is no formal written request from the lawyer.
Points of discussion 1. How should you respond to this request? 2. What should you be documenting in the case notes? 3. What in the MCA would be relevant in your consideration?
Case 2 Mr. Boo has schizophrenia and has a gangrenous right toe. He has diabetes, is a smoker and has been diagnosed with having peripheral vascular disease. He has refused a recommendation of an amputation below the knee, stating that after praying, he was told by God not to have the amputation. He wants his leg saved at all costs and is amenable to only conservative antibiotic treatment. In the last three days, his condition has deteriorated and he has developed sepsis. His family is in favour of surgical intervention to try and save his life.
Points of discussion 1. What are the steps to take in the evaluation of mental capacity? 2. What are the benefits of treatment versus non-treatment? 3. What are the burdens of treatment versus non-treatment? 4. Are there any precautions to take to avoid the above dilemmas?
Case 3 Mdm. Ah Siok has been admitted electively for a planned hysterectomy. The gynecologist has confirmed that she has fibroids. You are the ward House Officer. You clerked on the day of the admission and are now making all the necessary arrangements for the operation to take place. You decide against doing a uterine examination per vagina as Mdm. Ah Siok appears un-cooperative and tense. On the day of the operation, you assist the surgeon with the procedure. The surgeon turns to you once Mdm. Ah Siok is anesthetized, and enquires if a uterine examination has been performed, and if not, whether you would like to perform one before proceeding with the operation. You are momentarily dumbfounded and slightly in awe of the surgeon but are quick to recover your presence of mind and execute the examination, not wanting to let a good learning opportunity go to waste.
Points of discussion 1. Should you, the House Officer, have performed the uterine/vaginal examination beforehand? 2. What should you say to the surgeon in refusal? 3. What are your views about practising intubation on patients who are dead?
4 e s a C Mr. Zhou is 55 years old, has Trisomy 21 and has the mental capacity of a 7-year- old child. He is admitted and treated for pneumonia. Over the course of the next three days, his fever breaks but he refuses to eat. Feeding via an NG tube is instituted with much difficulty – Mr. Zhou is obviously miserable and tries to forcibly remove the tube and has to be restrained. Mr. Zhou’s widowed mother is his main caregiver and does not favour feeding via an NG tube and wants to take him home; she is not keen on invasive or expensive investigations/procedures such as scans. Mr. Zhou has obviously been well taken care of all these years. Mr. Zhou’s mother is worried that she will pass on before her son does. Mr. Zhou has a sister who is married and has her own family and is financially supported by her.
Points of discussion 1. Does the patient have mental capacity and if so, for what kinds of decisions? 2. What are the issues to be considered in your final decision?
Case 5 Ms. Koh is an 18-year-old unmarried woman admitted for an ectopic pregnancy. She is conscious and in severe pain upon being admitted to the hospital, accompanied by a close girlfriend. She verbally consents to the surgical removal of the ectopic growth and signs off on the consent form. Post operation, Ms. Koh is in need of a blood transfusion as a life-saving measure. It is at this time that Ms. Koh’s family shows up informing the treating team that they are practicing Jehovah’s witnesses, which precludes them from receiving blood transfusions. They request alternative life-saving measures be taken, which in the view of the treating team, will not be the standard of care. The treating team is unsure if it is appropriate to proceed with the blood transfusion, regardless of the patient’s religious convictions.
Points of discussion 1. What are the issues to consider in this scenario? 2. What would be your selected course of action if a patient arrives at the hospital in a confused mental state? 3. What would be your selected course of action if the same patient has on a bracelet that proclaims their affiliation with the denomination of Jehovah Witnesses?
If you wish to access the Case Studies in pdf format, please click on the pdf icon
Points for Reflection
Please view the following 12-minute video exploring a family’s first encounter with Advance Care Planning.
Play Video
Play Video
Making decisions about one’s end-of-life care or that of a loved one is not easy. Watch this Australian video that tells it all in only one minute.
Reflect on what: • Quality of Life means • Respecting a patient’s preferences means • Whom you would seek help from in managing difficult conversations