View Full Version : Lets try another one nurse natalie!!
02-15-2006, 08:40 AM
An 80-year-old Asian woman is hospitalized with weight loss, generalized weakness, and a pulmonary mass. Work-up reveals that she has pulmonary tuberculosis. Her family approaches the physician and asks that the patient not be told, stating that in her upbringing in mainland China tuberculosis was considered fatal and to tell her would be like giving her "a death sentence."
- Should you respect the family's concerns?
02-15-2006, 09:19 AM
I just wanted to say that I had to work through a scenario pretty similar to this at my Dalhousie interview last month, so I am anxious to see what the "right" answer is. The way I approached this quetion was 1. Is this woman Incapacitated? If she was, that, for me, is the only justification for not disclosing her condition to her. In that case one of these family members may be the substitute decision maker...2. Is there treatment involved? If so, I think she needs to be told her condition because treatment requires consent, informed consent. Informed consent indicates to me, that the patient must know their condition.
I said the family needs to be respected and all options discussed with them, but ultimately for me I felt that I could not be deceitful to the patient. I have NO IDEA if I approached this question the right way, and left the interview feeling like i hadn't. Can't wait to hear what others have to say...
Good luck on your interview!
02-15-2006, 09:59 AM
I just did a health ethics class and this kind of thing came up all the time. Not sure if this is right but I'll take a stab at it.
Firstly, determine whether or not she is capable of providing informed consent. As SnowflaX said- if she is not- this obviously impacts what happens next.
But let's say she does have the capacity to give informed consent. Firstly you have to determine whether her values are the same as her family's. Without first telling her of the condition, you can ask her how she feels about recieving certain types of information. If she says-tell me everything, I need to know etc... the choice is clear- you tell her.
However, she may defer to her family and their wishes. According to what I read- in many Asian cultures family autonomy is more important than individual autonomy. If this is the case-and the patient clearly indicates that she does not want the info and/or the info should be passed on to the family- you should respect her choice.
You should not force information onto people if they (not their family) have clearly said they do not want it-however, you must always be open to providing infomation should the patient change their mind. Consent is a process- and things may change day to day.
Anyways that's my take on it....
02-15-2006, 12:12 PM
This is the answer supplied by the medical bioethics person who made the question.
- Some cultures hold different beliefs about truth-telling in the medical encounter. Some assert that in some Asian cultures, members of the family unit may withhold the truth about terminal illness from elders out of respect and a desire to protect them from harm. If a patient and their family members hold such beliefs, they should be respected, and a mechanism for informed decision making in collaboration with the family negotiated. One must not, however, assume that every patient of Asian ancestry holds the beliefs described here.
02-15-2006, 12:41 PM
OMG, the exact same scenario happened in real life for my friend's family a few weeks ago. Nice question! Nacho174's solution was exactly what the doctor did.
02-15-2006, 02:33 PM
great answers! I'm always amazed at my reaction level when I read different cases! but then, that's ethics for ya! ;)
so, we kinda decided this woman is capable...right?
I am shamefully guilty of not knowing the Asian culture very well ! although a 'diagnosis of death' is significant and is something that I would need to address... the issue of needing her consent before she can be treated takes precedence for me.
this person has TB... which is highly infectious. Yes, you could screen and treat all the people around her without her knowing- but you can't treat HER without her consent!She needs to know what will happen from the illness and from the treatment that you will give her. You HAVE to treat her, so the only way you can do that- is by giving her the diagnosis (well... she can refuse treatment from you, but then the medical officer of health has the legal authority to force the patient to receive treatment against their will- to protect the public).
3) the fact that its TB complicates the case a tad.... because this is a reportable disease and you are mandated to report it to the health unit and they will do the screen and tracking (obviously, you wouldn't be expected to know this before your interview- its something I know because of my background !).
giving treatment to a patient without their consent (after determining they are competent to make the decision) is a professional misconduct and there are a few laws to protect the public against this .. so, that kind of takes that option to not disclose away from you in this case (because this HAS to be treated, and HAS to be reported !) I would make sure to take a lot of time to teach HER and the family.. to change the view about diagnosis...
i dont know.. this is hard.. but I would tell her the diagnosis... because its TB.. but that's just my thoughts
(and please.. just call me Nathalie... or Nat) ;)
02-15-2006, 04:53 PM
Great points Nathalie!
I was in Nepal for a while volunteering in hospitals and I ran into a lot of TB cases. It was interesting to hear about these cultural differences- I had never come upon a family that did not want the patient to know. I guess maybe Nepal (although an Asian country does not have these same values).
I agree with everyone how it is very important to keep people's personal wishes and cultural beliefs in mind when diagnosing, treating and interacting with them. However, Nathalie has brought up some great points on when we can't legally follow all their wishes. But being very culturally sensitive, and like Nathalie said "take a lot of time to teach HER and the family.. to change the view about diagnosis...", I think we have done the best we can to maintain respect for the family and patient, but also protect the public and fulfill our duties (should we be accepted) as doctors.
Should this woman have a different diagnosis (other than TB) I still think it is extremely important to make sure the patient is aware that there is information to be disclosed. If the patient herself refuses information, that is a whole other problem. I don't think it should ever stop at the family for someone who is capable of understanding and consenting.
It is interesting how many variables come into these ethics questions. I don't know if there is ever one RIGHT answer, just variations of good decisions.
02-15-2006, 07:20 PM
thats the interesting thing... we're NOT doctors yet.. so we aren't expected to have all the answers! we will learn more about how to handle such cases in the future... buteven without the background, you can still have an opinion.
a very important aspect of medicine, is 'intention'. if you mean well, and are looking out for the best interest of the patient, then you can justify why you would or wouldn't tell the patient a diagnosis (in some cases).
just pick a side, and back it up with a rationale of WHY you chose that side..and stick to it - and you won't go wrong !
02-15-2006, 08:17 PM
Hi I'm at NOSM. Our curriculum has been bombarded with these ethical dil's.
I definately agree with Nat... a patient must be told of their condition unless the patient specifically askes not to be told (not the family). This used to be the opposite with medicine's "paternalistic philosophy" from 30 years back where "doctor knew best". You definately NEVER treat a patient without consent, and you NEVER make a decision for a patient... you help them make an informed decision.
Remember that for the patient to have "capacity" to make a decision, the patient must be able to understand:
1- her sickness
2- understand treatment options
3- understand the pros and cons of treatment
4- be able to chose one
*the issue is when they ask your opinion!!
02-15-2006, 10:16 PM
Interesting that no one has brought up the possibility that confidentiality may have been broken...how does the family know the diagnosis before the patient?
Food for thought...
02-15-2006, 10:22 PM
Good call JewelLeigh!
And I lied in my last post... there are special cicumstances where you don't need consent (emergency where delaying treatment for consent would cause harm).
Treating children and teens is a something I would think about... involving parents in the treatment.
02-16-2006, 12:25 AM
priapismsarebad and any other present NOSMs - please tell me, are all of the students in your class going to remain in the north? how much of an expectation is it, especially for people from OOP? i suppose if i meet someone and want to remain there i would but otherwise i would come back here...how well would that be taken?
02-17-2006, 12:24 AM
I assume a number of students from every year will not stay to practice in the North or in rural areas. They installed a similar school in rural Australia and half the students stayed... I assume they expect similar numbers or more. But like you said you may meet someone here. 4 years is a LONG time.
02-17-2006, 05:58 PM
Do they ask outright about intention to remain in north?
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