Case study: End of Life Care

Keywords: end of life care family, family help palliative care

In describing a situation in which my integrity was challenged I would first like to give some background. This involved a patient I cared for and I will anonymize the situation for privacy concerns – he will be referred to as Patient A. The patient was a middle aged male who had been diagnosed with cancer. He initially declined therapy due to personal beliefs that he and his wife had about alternative medicine. A year later, with progression of his cancer, he agreed to chemotherapy but by then his cancer was very advanced. He initially came under my care at the end stage of his cancer, and when I admitted him I did not expect he would survive to discharge. His wife was of the opinion that he had declined because he agreed to chemotherapy and expected him to improve now that chemotherapy had been stopped. During his admission he improved and was discharged. At discharge I went over his condition with him and his wife, and discussed his expected continued decline in detail.

About one month after this I again admitted Patient A. He was in very bad shape and had not eaten much for about a month. He needed to be admitted to the Intensive Care Unit. He was lethargic, with a waxing and waning mental status. I was worried that he would not be able to swallow properly and would likely aspirate (with attendant complications including pneumonia) if fed, so I held off on feeding him till his mental status improved, sustaining him in the interim with intravenous nutrition/fluids. I also stopped some medications he had been on prior to admission including synthroid, a medication for thyroid dysfunction. I initially discussed Patients A’s condition with him (when he was more awake) and he decided he did not want to be resuscitated if his heart stopped. When his wife was available I sat down with her and we had a long discussion concerning his condition and his prognosis. She was very personable but was convinced that his prognosis was better than I was making out. She was also very concerned about Patient A not eating and not getting his thyroid medications. I explained the rationale for my not wanting him to eat yet and explained that thyroid medication could worsen a complication he had at that time. Despite our conversation she was still convinced that his prognosis was pretty good. I ended the conversation by asking her to think on things and promising to discuss further with her at a later time. However, when I did see her later she accused me of not taking adequate care of her husband. She felt I was giving up on him and leaving him to starve. She also felt he would be doing better with his thyroid medication. She requested that a different physician be put in charge of her husband.

Taking care of patients at the end stage of life can be difficult. It is especially so when the patients are relatively young. The surviving family members also often have survivors’ guilt, with a propensity to feel they could have done more. In this case Patient A’s wife believed there was a lot more that could be done that could change the outcome.

I felt her accusation was a challenge to my integrity and was very taken aback, especially as I thought we had come to an understanding when last we spoke. She was essentially accusing me of not only inadequate care but of harming my patient. I gave Patient A’s primary care physician a call to discuss how she had been interacting with Patient A and his wife. I then sat down again with Patient A’s wife and we had another long discussion at the end of which I agreed to let Patient A try to eat. I agreed to this understanding that he could aspirate. In view of his expected imminent demise I felt if he could get some comfort from eating, it would be worthwhile. However I did not agree to recommence Patient A’s thyroid medication which would at that point have hastened his demise.

I believe I was at fault in not adequately addressing her concerns initially. She was seeing individual trees and not the forest. But I was also taking a coldly clinical approach. While I was clinically right, a deeper view should have shown me that at that point his comfort and his wife’s satisfaction that he had received appropriate care should have been paramount.