Dillemma In Clinical Medicine

Dilemmas in Clinical Medicine, Sample Case Write-up

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Dilemmas in Clinical Medicine

A 28 year old male was admitted to the hospital with

chief complaints of longstanding back pain, and left eye droop

for several weeks. He also had experienced some fecal

incontinence. He had been followed by this current PMD over the

previous 5 months. The PMD provided the past history of

Hodgkin's Disease for the past 5 years. He was initially treated

with chemotherapy and went into remission. Approximately one

year ago he began to have back pain and paraparesis, and an

epidural mass was found. He began radiation therapy but

frequently missed appointments.

He had first presented to the PMD 5 months ago bringing

photocopies of all of his medical records. He indicated that he

had been seeing an oncologist who was treating him with

radiation. Admitting his non-compliance, he said he was tired of

all the cancer treatment and only wished to have symptomatic

treatment of his pain so he could "live out my time" peacefully

without pain. He said the oncologist would no longer treat him

if he did not go for the radiation. He had been receiving

Dilaudid from the oncologist and wished to continue it. The PMD

wrote a prescription for it and referred the patient to hospice.

Soon thereafter, the PMD was visited by a narcotics agent

from the NYS Health Department who indicated that this patient

had visited many physicians with the same story and had been

getting multiple prescriptions. The patient met with the agent

and the PMD in the doctor's office and agreed to restrict

himself to this doctor in the future. A short time later, the

patient's mother called the doctor and reported that the patient

has been addicted to drugs for many years (before the Hodgkin's)

and simply used the illness to his advantage to obtain drugs.

Before the PMD could confront the patient with this, he was

admitted for the current hospitalization.

On examination, the patient was lethargic and febrile. He

had a dilated left pupil and nystagmus. His rectal tone was

diminished and when catheterized, had a large amount of urine,

indicating urinary retention. He rapidly became delirious and

then unresponsive. Neurologic W/U revealed obstructive

hydrocephalus. Neurosurgery placed a V-P shunt and he improved

modestly. When he worsened, the surgeons said the shunt was

obstructed, but they would revise it only if the patient

received aggressive anti-tumor treatment (RT and chemo).

The patient's mother was consulted and she said she would

not want the aggressive treatment because "it wouldn't make a

difference; he'll still be a drug addict."

Discussion:

PROBLEM:

How do we make a substituted judgment for an incapacitated patient whose

prior statements were of questionable authenticity (because they were part

of an attempt to obtain drugs for abuse)?

ISSUE:

Standards for Decisions When Patients Lack Decision-Making Capacity

QUESTION:

Should we forgo shunt revision (with RT and chemo) and allow this patient

to die?

The Dilemma is whether to provide radiation/chemo to this

incapacitated