Ethical Case Discussion Case8 and Case9
(Patient Autonomy and Informed Consent)

I want to ask you the new case discussion on the Patient Autonomy
(Capacity ) and how to do Informed Consent in the following cases.

Case8) 38years old man.
He stayed in a sauna for several weeks. He has been suffering
from cough and dyspnea for several days.
He falled down in a sauna and sent to the emergency  room.
In the emergency room as his blood oxygen level was low and carbon
dioxide level was high,the endotracheal intubation was needed.
But the patient said "Please do nothing because as it is painful"
What does the chief physician to do?

Case9) 83years old woman.
She is a midwife who was suffering from hypertension for several years.
Her husband died several years ago owing to lung cancer.
She has no children and she lives only by herself now.
She said to the family physician "My husband died in hospital not
peacefully with many tubes. If I will suffer from fatal disease, I
want to dye at my home."
She was suffering from cough and dyspnea and came to her family doctor's
clinic. Her oxygen level was low and oxygen was given to her by nasal tube.
She looks feel better by the oxygen therapy.
Her chest Xp showed central lung cancer and secondary pneumonia.
Her condition needs hospitalization to take antibiotics infusion.
But the patinet said "I don't want go to the hospital"
What does the family physician do?

Comments on these Cases

Yeruham Frank  Leavitt, Ph.D.
Chairman, The Centre for Asian and International Bioethics
Faculty of Health Sciences
Ben Gurion University of the Negev
Beer Sheva, Israel

I think there is a difference between the two cases because the man (case
8) who fell in the sauna, is already hospitalized, already under medical
and nursing care.  I think there is room here for a kind of "gentle
coercion".  I don't mean really forcing the patient to acceppt the
treatment.  But a gentle and friendly, smiling nurse -- for example --
ought to know how to just go ahead with the treatment, ignoring the
patient's protests in a nice way, while perhaps chating with him about
other things.  I think that if this is done right the patient is very
likely  to accept the treatment with no real complaint and to say
thank-you afterwards.  The way the case is described, I do not see this as
a serious objection to treatment:  just normal fears which is is the job
of nursing to overcome in a friendly way.  I emphasize nuirsing because I
think that many ethical problems can be solved by good nursing, rather
than having doctors and philosophers debate them.

But every case must be judged on its own merits.  I don't believe in
axioms in clinical ethics.  And the other case  ( case 9) is different.  I
would try gentle persuasion here also but would not ignore the woman's
very legitimate statements. After making every effort at gentle persuasion
(by the physician, nurse, neighbors, etc -- if she still refuses to go to
hospital, I would tend to respect her refusal, given the details of the
case as described.

Howard Brody

Department of Family Practice and Center for Ethics and
Humanities in the Life Sciences, Michigan State University
East Lansing, MI USA.

Case 8: This fairly young man has no special reason to refuse intubation and
ventilation based on experience with chronic disease, or fear of lowered
quality of life if he receives life prolonging treatment. (This would be
different, for instance, if he had cystic fibrosis and had been several times in
an ICU on the ventilator.) So it appears that his main concern is simply
the painfulness of the procedure itself. Plus since his blood gases are
markedly abnormal, this could indicate a disorder in ability to process
information consciously.

It seems to me that this is a fairly unusual situation because the patient is alert
enough to make a coherent statement about not wanting the ventilator, and yet
severely enough afflicted so as to make intubation medically indicated. More
commonly, the patient who is being intubated in the emergency department is
unable to speak coherently at all.

At any rate, since this unusual situation has arisen, I would recommend
addressing the pain issue head on. Intubation need not be painful if the patient
is adequately sedated, and this can be offered to him. Else he could be given
a fast-acting narcotic. There is of course some medical risk that the drug
to relieve pain will further decrease respiratory drive or worsen the gases, but
as he is being immediately monitored and will soon be intubated and ventilated,
this small risk seems worth while in the name of compassionate care of the patient.

Case 9: This case seems to me less controversial because the patient can be given
oxygen by nasal cannula and therefore can have her hypoxia corrected to be sure
that her first decision is not induced abnormally by the low oxygen to the brain.
If she then confirms her very reasonable desire to die at home, then I see no ethical
grounds for forcing treatment on her. In the US, depending on the insurance situation,
one could offer home IV therapy. One could also offer her home hospice care which
would in many ways be the best overall option, if there were someone in the home
available to assist with her care.

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If you kindly give me your comment on this case, please send me your E-mail to the following E-mail adress.
And if you have interest in these case discussion, I hope to send you the new cases.
Please tell me your E-mail adress.

Masashi Shirahama M.D.
Director, MItsuse National health Insurance Clinic
Lecturer, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan

TEL0952-56-2001, FAX0952-56-2912
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