Cases:MrLau

Introduction
Backgrounders
Themes

Case: Mr Lau

Conflict between team members

Mr. Lau is an 89-year-old long-term resident at a home for the aged. He started living at thehome about 8 years ago after he was hospitalized for a stroke resulting in right-sided weakness and became wheelchair bound. He was never married and has two sisters who visit him every now and then.

Two weeks ago, Mr. Lau was admitted to the hospital after falling from his wheelchair and broke his hip. He was admitted to the orthopaedics ward. Dr. Shan, the orthopaedic consultant felt he was not a surgical candidate for hip replacement due to his poor underlying health status and he was already wheelchair-bound. Over the next few days, Mr. Lau developed a fever and cough, and was diagnosed with pneumonia. Despite being treated with antibiotics, his respiratory status worsened. He struggled to maintain oxygenation despite being on the maximum amount of oxygen that can be delivered to his face mask.

Given his deteriorating condition, the orthopaedics medical officer, Dr. Lo, phoned Mr. Lau’s sisters and explained: “Your brother has a serious pneumonia. If we don’t connect him to a breathing machine soon, he will soon die.” His sisters agreed with inserting a breathing tube, and Mr. Lau was connected to a ventilator. A feeding tube was inserted and tube feeds were initiated.

Dr. Hong is the intern who has been caring for Mr. Lau over these past few weeks in the hospital. Now that Mr. Lau is on the breathing machine, Dr. Hong was distressed at doing repeated arterial blood draws on the patient to monitor Mr. Lau’s blood gases because of the pain the procedure caused. Both his arms were badly bruised from the frequent blood draws. He felt that keeping Mr. Lau alive on the ventilator was torturing the patient. He did not think that his senior Dr. Lo had a proper informed discussion about the risks and benefits of the treatments with his family.

Fortunately, after a week on the ventilator, Mr. Lau’s respiratory status improved, and he was successfully extubated.

A day later, however, Mr. Lau was having more difficulty breathing again. Dr. Lo spoke with the consultant Dr. Shan who agreed with re-intubating the patient. He then told Dr. Hong to call the anesthesiologist to come to perform the intubation. Dr. Hong became concerned that putting Mr. Lau back on the ventilator would be futile treatment since he is unlikely to leave the hospital alive and it would only serve to prolong his dying and increase his suffering. He is uncertain whether or not to follow his senior’s orders to call the anesthesiologist.

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– Dr. Tse Chun Yan, Chairman, HA Clinical Ethics Committee (2005 to 2017)

Dr. Hong was concerned that further intubation and mechanical ventilation would be futile and not in the best interests of the patient. Whether this view is appropriate would depend on the following factors:

  1. Was the patient still competent?
    Being 89 years old and having a stroke does not necessarily mean that the patient was not competent. If the patient was still competent, the view of the patient should be sought.
  2. How was the quality of life of the patient before the accident?
    Being 89 years old and wheelchair bound from a stroke does not necessarily mean that the patient had a poor quality of life. Quality of life is one important consideration in balancing the harms and benefits of an invasive treatment.
  3. Was there input from a relevant specialist about the prognosis on further intubation?
    Dr. Hong’s consultant, by deciding to re-intubate the patient, indicated that there was still a chance of recovery from the pneumonia. However, Dr. Hong considered further treatment futile. Dr. Hong himself was a house officer, while his consultant was an orthopaedic specialist. In view of the difference in view, it would be useful to seek a second opinion from a relevant specialist, e.g. in geriatrics or respiratory medicine.
  4. If the patient was already incompetent, did the patient previously express his values and preferences regarding life sustaining treatment?
    If there was a chance of meaningful recovery from the pneumonia, knowing the patient’s prior values and preferences would be important in deciding whether to re-intubate or not.

If, after considering the above factors, Dr. Hong considers that re-intubation would be futile and not in the best interests of the patient, it would be proper that he does not simply follow the instruction of his senior without question. Dr. Hong has an ethical duty to exercise his own independent professional judgment and to act in the patient’s best interests.

It would be appropriate to discuss further with his seniors, to raise his views and to suggest seeking a second opinion from a relevant specialist. Because what is in a patient’s best interests is often a value-laden decision, in making the decision, it is useful to build consensus with the patient and his family members and among members of healthcare team, taking into account views from different perspectives.

If consensus cannot be reached within the healthcare team, if time allows, the clinical ethics committee of the hospital can be consulted. Another alternative is to consider a time-limited trial of treatment. The healthcare team should work out with the patient and family a well-defined set of therapeutic goals and end points and a well-defined period of trial time. If no progress is made towards the agreed therapeutic goals at the end of the trial period, decision can be jointly made to withdraw the life sustaining treatment.