Case Studies – A Family Divided Case Studies:
A Family Divided
A Case Study by Robert L. Potter
Discussion Questions by Rosemary Flanigan
A forty-five-year-old man with a three-year history of cardiovascular disease has entered the hospital with a stroke that has paralyzed his right side and caused him to aspirate food of any consistency. His mental status is clouded and there is disagreement as to whether or not he has decisional capacity. His language capacity is only “yes” and “no,” and his responses are inconsistent. The attending physician is convinced that the patient has lost decisional capacity while two family members are equally convinced that he has decisional capacity. The patient’s wife and two other children are ambivalent about his competency to make decisions. The prognosis for recovery of safe swallowing and speech approaches zero because of the dense damage to the cerebral cortex visible on brain imaging. Two neurological consultants have verified that recovery is likely to be minimal and that permanent, severe disability will be the outcome.
The patient does not have an advance directive. The patient’s wife says that they never did discuss his preferences about life-sustaining treatment. She is convinced that he would not want to live in this disabled condition, but is uncertain whether to request the placement of a feeding tube. Two of her four adult children are strongly opposed to the tube placement, while the other two insist that not to do so would be to “kill our father.” The patient’s wife is torn between these two positions, but finally requests that the tube be placed.
The attending physician and the rest of the treatment team are opposed to placing the feeding tube. Their argument is that the patient has “minimal consciousness” and will not improve. They define this as a futile situation with no reasonable expectation of recovery. Furthermore, two nurses claim that during previous hospitalizations for episodes of cardiovascular events the patient told them that he would not want to be sustained by artificial means — not by ventilators, renal dialysis, or tube feeding. It is their position that the patient has expressed his preference to not be kept alive in a futile situation.
The family requests an ethics consultation.
Questions for discussion
1. The judgment of futility should be a conclusion of a communications process, not a beginning. How would you propose beginning the communication?
• Who should be present?
• What information should be shared?
• What alternatives are on the table?
• What is your goal in participating in the discussion?
2. The family is divided over whether or not their husband/father should be placed on a feeding tube. Consider and discuss the following statements:
• The effectiveness of the feeding tube is a clinical matter.
• The benefits of the feeding tube for the patient depend on the patient’s wishes and quality of life, which the patient or the patient’s surrogate and family must determine.
• The burdens the treatment (feeding tube) imposes are a consideration for both parties.
3. Role play the discussion. Express your assumptions and loyalties and listen attentively to the other speakers.
4. Evaluate the role playing experience. Did it affect your view of the case?
If yes, how will you advise the family and the healthcare providers?
If not, what is to be done now?
5. How would this case have been different if the attending physician had been the one asking for a consultation?
Expert Solution Preview
Introduction:
The following case study presents a complex ethical dilemma that arises when a patient with a history of cardiovascular disease experiences a severe stroke that renders him incapable of making medical decisions. The patient’s family is divided on whether or not to place a feeding tube, and the attending physician and treatment team are opposed to the idea. The case study raises critical questions about medical ethics and decision-making in such scenarios.
1. How would you propose beginning the communication process in cases such as this?
When dealing with complex ethical dilemmas involving a patient and their family, it is essential to initiate communication in a compassionate and empathetic manner. The physician should ensure that all family members are present and informed of the patient’s condition, prognosis, and possible treatment options. It would be advisable to provide information about the expected outcomes of each treatment modality in detail to ensure that the family understands the implications of different decisions. The primary goal of the discussion should be to build trust, establish a rapport, and encourage open and honest communication between all involved parties.
2. The family is divided over whether or not their husband/father should be placed on a feeding tube. How should the benefits and burdens of the treatment (feeding tube) be addressed?
When considering the decision to place a feeding tube in a patient with severe disability, the benefits and burdens of the treatment must be weighed carefully. It may be beneficial to invite the patient’s surrogate decision-maker and family members to discuss their concerns and preferences regarding the treatment plan. The physician should also explain the possible risks and benefits associated with feeding tube placement and discuss the patient’s quality of life in the context of the treatment plan. Ultimately, the decision should be guided by the patient’s preferences, values, and goals of care.
3. Role-play the discussion. Express your assumptions and loyalties and listen attentively to the other speakers.
During the discussion of the family’s conflict, it is vital to express empathy and understanding towards each party’s opinion. It would be advisable to listen attentively to their concerns, assumptions, and loyalties. At the same time, the physician should remain unbiased and focused on the patient’s best interests while guiding the discussion towards a resolution that benefits the patient.
4. Evaluate the role-playing experience. Did it affect your view of the case? If yes, how will you advise the family and the healthcare providers? If not, what is to be done now?
The role-playing experience allowed me to understand the importance of empathetic communication and active listening. By adopting a non-judgmental attitude, it is possible to build a rapport with the family and establish a dialogue in cases of complex ethical dilemmas. I would suggest that the physician initiates a shared decision-making process that considers the patient’s values and preferences and involves the family in the treatment decision. At the same time, the physician must make their best medical judgment to ensure that the decision aligns with the patient’s overall goals of care.
5. How would this case have been different if the attending physician had been the one asking for a consultation?
If the attending physician had requested a consultation, they would have been able to engage with the ethics committee earlier in the process, potentially preventing any familial conflicts from escalating. Involving an ethics committee may have facilitated a shared decision-making process that satisfied all parties involved. Additionally, the attending physician’s perspective would have been an essential component in determining the decision’s final outcome.