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Bioethics Case

ANDAL, ANDALES, ANG. Bioethics Case. HISTORY. GENERAL DATA MA, 43/F, married, Roman Catholic, R-handed from Quezon City CHIEF COMPLAINT Dyspnea. CLINICAL HISTORY. PATIENT PROFILE

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Bioethics Case

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  1. ANDAL, ANDALES, ANG Bioethics Case

  2. HISTORY GENERAL DATA MA, 43/F, married, Roman Catholic, R-handed from Quezon City CHIEF COMPLAINT Dyspnea

  3. CLINICAL HISTORY PATIENT PROFILE A diagnosed case of Breast CA, Stage 3B (Apr 2008); undergone 4 cycles of chemotherapy (latest session Mar 2009 PGH-CI) Nondiabetic and non-asthmatic

  4. HISTORY OF PRESENT ILLNESS 4 months PTA, pt’s chemotherapy session was deferred due to decreased Hgb in CBC results and occurrence of left pleural effusion. Pt was lost to follow-up and noted to be experiencing dyspnea, necessitating nebulization with salbutamol at least 4x/day. 3 weeks PTA – pt had onset of cough with whitish phlegm, (+) easy fatigability, fever (relieved by paracetamol 500 mg/tab prn), 2-pillow orthopnea

  5. HISTORY OF PRESENT ILLNESS 2 weeks PTA, worsening of dyspnea, admitted at New Era Hospital, A>Malignant Pleural effusion P> chest tube thoracostomy (L) Meds: tramadol, co-amoxiclav, other unrecalled meds 3 days PTA, discharged slightly improved; referred to PGH for 2D echo and continuation of radiation therapy; still with mild dyspnea Day of admission: worsening of symptoms, (+) generalized weakness, consulted at PGH, admitted

  6. REVIEW OF SYSTEMS • (-) fever, (-) vomiting (+) anorexia, (+) weight loss, (+) easy fatigability • (-) headache, dizziness, cough, colds, epistaxis, BOV, otalgia • (+) chest pain (-) palpitations • (-) abdominal pain, diarrhea, constipation, hematemesis/melena/hematochezia • (-) polyuria, polydipsia, polyphagia • (-) hematuria, frequency, dysuria, urgency • (-) cyanosis, jaundice, seizures, (+) pallor

  7. Past Medical History • (+) HPN (1997, uncontrolled) • (+) Goiter (2000) • (-) PTB, DM, BA • (-) allergies to foods and meds • (-) previous surgeries Family Medical History • (+) HPN, BA – both parents • (-) Goiter, DM, allergies • (-) history of cancer in the family Personal/ Social History • Patient is a college graduate, a graduate of midwifery, but worked as a saleslady until 1996. She is married with 2 children. His husband is an OFW and is the breadwinner of the family. The patient has no vices. She denies illicit drug use.

  8. Pertinent History Findings • 53/F, married • Diagnosed case of Breast Cancer Stage 3B • s/p 4 cycles of Chemotherapy • Admitted at another institution with the diagnosis of Malignant Pleural effusion • Referred to PGH for further work-up and radiotherapy • College graduate, midwifery

  9. PHYSICAL EXAMINATION

  10. COURSE AT THE ER • 1st HD 7/19/09 Patient hooked to O2 support at 10 lpm via face mask; A> Malignant pleural effusion, L, s/p CTT (July 2009) vs Obstructive Pneumonia, Breast CA t/c pulmo metastasis. • Labs: ABG done which showed respiratory alkalosis (compensated). CBC done showed elevated WBC and neutrophil counts (infection) • Meds: Piperazillin + Tazobactam 4.5 g IV q 8h , paracetamol 500 mg/tab q 4 for fever prn. • POD II: A> Breast Carcinoma Stage IV with Liver Metastasis (t/c Lung Metastasis) with Secondary Bacterial Infection, Malignant Effusion, R; s/p CTT with pleurodesis (July 2009), Hypertension, controlled. • Meds: Shift Pip-Tazo to 1) Oxacillin 2 g IV Q6 2) Clindamycin 300 mg/cap 1 cap Q6 PO. Maintained O2 at 4 lpm via NC. (Referred to TCVS for CTT, Hospice, Med Onco)

  11. 2nd HD 7/20/09 DAY MHAPOD: Pertinent PE: Pale conjunctivae, + chest lag, L,decrease breath sounds and fremiti, L, (-) crackles/wheeze. (+) breast mass, L with purulent discharge. • Labs: Chest UTZ with markings, PBS with reticulocyte count. • Meds: Discontinued clindamycin; Start levofloxacin 500 mg/tab OD; Start Moriamin Forte 1 cap BID; Appeton 500mg/tab at HS OD. Continue other meds; (Referred to GS1 for possible thoracentesis.) CDW BID of breast mass wound with Daikin’s Solution. • DAY MHAPOD: S> (+) pleuritic chest pain, lung findings unchanged. • Meds: Continue Oxacillin, hold clindamycin. To start Levofloxacin at 750 mg OD. Continue other meds. Transfusion 4 ‘u’ FFP now then 2 ‘u’ Q12; transfuse 1 ‘u’ pRBC; (Surgery referral done once with chest markings.)

  12. 3rd HD7/21/09 DAY MHAPOD: Patient noted to have decreased serum Mg • P> IVF: MgSO4 drip: 3 g MgSO4 + 250 D5W x 12 hrs; IL pNSS x 12 hrs. • 4th HD 7/22/09 NIGHT MHAPOD: Enalapril 20 mg/tab OD started • 5th HD 7/23/09 NIGHT MHAPOD O> decreased breath sounds over L base, (+) decreased breath sounds over the R mid-base, (+) vocal fremiti B bases • Meds: Continue Oxacillin (D0 + 3), Levofloxacin (D2); Plan was to insert CTT c/o TCVS; Patient admitted at W1B19.

  13. Physical Examination PE on Ward Admission

  14. ASSESSMENT Breast Carcinoma Stage IV with Liver Metastasis (t/c Lung Metastasis) with Secondary Bacterial Infection Malignant Effusion, R s/p CTT with pleurodesis (July 2009) Hypertension, controlled

  15. COURSE IN THE WARDS • 6th HD 7/24/09 Patient is persistently tachypneic, BP 120/80, HR 120, RR 36, O2 sat remains 97-98%; refused to be intubated; signed with advanced DNI directive. • 7th HD 7/25/09 11PM Patient referred for decreased BP of 70/50, HR 50s, RR 12, O2 sat at 60%. Soon after, code was called, CPR was started with O2 support via facemask and ambubag. • Patient’s husband arrived and decided to reversed previous DNI directive. Patient then intubated and ACLS was started. Patient was revived after 4 min of cardiopulmonary arrest. Patient was hooked to Dopamine and mechanical ventilator.

  16. 8th HD 726/09 Still hooked to Dopamine 2 ampules in 250 cc D5W at 48 cc/hr (20 mcg/kg/min) at max dose; BP was stable at 110-90/70-60, HR 140s, RR48; • Patient’s husband reluctant to pursue further laboratory exams; DNR was comtemplated but never consented. • 10 AM Patient’s BP went down to 70/40; Dobutamine drip was started as ampules in 250 cc D5W @ 36 cc/hr at max dose. BP maintained at 90-70/60-40. No further inotropes started.

  17. 9th HD 7/27/09 9 AM Patient referred for BP 60/40, HR 68, RR 36; Soon after, second code was called; ACLS was started. At 9 mins post arrest, pt’ s husband decided to stop further resuscitation attempt. Patient maintained on O2 support via facemask on CAB; no CPR was pursued until cardiac monitor read as asystole. Patient was then declared dead.

  18. Will you intubate and resuscitate? Bioethical Dilemma

  19. Scenario • (6th HD 7/24/09) the doctor explained to the patient that anytime her condition can deteriorate. At this time the patient was conscious, coherent and competent to make decisions for herself. • She was asked if she wanted to be intubated once her condition deteriorates. However, the patient and her husband refused.

  20. (7th HD 7/25/09 11PM) Patient’s condition worsened • BP70/50 HR50s RR12 • O2 sat at 60% • code was called, CPR was started with O2 support via facemask and ambubag. • At this time, the patient’s son was the only one around • No attempt for intubation was done • Son was informed of the importance of intubation however there was an advance directive of DNI, thus the patient was not intubated

  21. Patient’s husband arrived • Family was appraised of the patient’s condition • The husband decided to reverse previous DNI directive • Patient was then intubated and ACLS was started. • Patient was revived after 4 min of cardiopulmonary arrest. • Patient was hooked to Dopamine and mechanical ventilator.

  22. 8th HD 7/26/09 • Patient’s husband reluctant to pursue further laboratory exams; • DNR was comtemplated but never consented

  23. 9th HD 7/27/09 9 AM • Patient referred for BP 60/40, HR 68, RR 36; Soon after, second code was called; ACLS was started. At 9 mins post arrest, pt’ s husband decided to stop further resuscitation attempt. Patient maintained on O2 support via facemask on CAB; no CPR was pursued until cardiac monitor read as asystole. Patient was then declared dead.

  24. Pertinent points • When the patient was competent, she refused to be intubated • The husband retracted the DNI order • Was it ethical to follow the husband’s retraction of the DNI order?

  25. Bioethical Principles

  26. Autonomy • affirms that we ought to be the authors of our own fate, the captain of our own ship • emphasizes the personal responsibility we have for our own lives • the right to choose who we wish to be, to make our own decisions and to control what is done to ourselves • includes the capacity to deliberate about a proposed course of action as well as the ability to actualize or carry it out

  27. Advance Directive • This is a document which indicates with some specificity the kinds of decisions the patient would like made should he be unable to participate. • In some cases, the document may spell out specific decisions, while in others it will designate a specific person to make health care decisions for them

  28. Surrogate decision maker • In the absence of a written document, people close to the patient and familiar with his wishes may be very helpful • The law recognizes a hierarchy of family relationships in determining which family member should be the official "spokesperson” • Legal guardian with health care decision-making authority • Individual given durable power of attorney for health care decisions • Spouse • Adult children of patient (all in agreement) • Parents of patient • Adult siblings of patient (all in agreement)

  29. Issues • The patient’s autonomy was not recognized. • At the time that the DNI order was signed, the patient was conscious, coherent, able to follow commands, and with intact higher cortical functions • She was able to… • understand her situation, • understand the risks associated with the decision at hand, and • communicate a decision based on that understanding. • therefore the patient was competent to make a decision

  30. Beneficence the positive expression of nonmaleficence highlights that we have a positive obligation to advance the healthcare interests and welfare of others, to assist others in their choices to live life to the fullest.

  31. Indications for Intubation In conditions of, or leading to resp. failure, such as; • trauma to the chest or airway • neurologic involvement from myasthenia gravis, poisons, etc. • CV involvement leading to impairment from strokes, tumors, infection, pulmonary emboli • CP arrest

  32. Indications (cont’d) • Relief of airway obstruction • Protection of airway (I.e. seizures) • Evacuation of secretions by tracheal aspiration • Prevention of aspiration • Facilitation of positive press. ventilation

  33. Issues • Intubation will ensure adequacy of oxygen going into the lungs and circulating in the body • CPR will prolong life

  34. Nonmaleficence First of all, do no harm. imposes the obligation not to harm someone intentionally or directly not necessarily violated if a proper balance of benefits exists; that is, if the harm is not directly intended but is rather an unfortunate side effect of attempts to improve a person's health or, at the very least, to provide relief from the burden of pain.

  35. Hazards of tracheal tubes & cuffs • Infection • Trauma • Dehydration • Obstruction

  36. Hazards (cont’d) • Accidental intubation of the esophagus or right mainstem bronchus • Bronchospasm, laryngospasm • Cardiac arrhythmias resulting from stimulation of the vagus nerve • Aspiration pneumonia • Broken or loosened teeth

  37. Later Complications of Intubation • Paralysis of the tongue • Ulcerations of the mouth • Paralysis of the vocal cords • Tissue stenosis and necrosis of the trachea

  38. Justice the allocation of healthcare resources according to a just standard Comparative justice involves balancing the competing claims of people for the same health care resources what one receives is determined by one's particular condition and needs. Distributive justice determines the distribution of health care resources by a standard that is independent of the claims of particular people Distribution is determined according to principles rather than individual or group need.

  39. Issues • Was the patient was treated according to the standards of care?

  40. Learning Points • The patient’s autonomy should have been respected. • At the time that the DNI order was signed (patient was still competent), it should have been explained to the family that the order is final and cannot be reversed even if the patient’s condition deteriorates.

  41. Invictusby William Ernest Henley. 1849–1903 OUT of the night that covers me,     Black as the Pit from pole to pole,  I thank whatever gods may be     For my unconquerable soul.     In the fell clutch of circumstance I have not winced nor cried aloud.  Under the bludgeonings of chance     My head is bloody, but unbowed.     Beyond this place of wrath and tears     Looms but the Horror of the shade, And yet the menace of the years     Finds, and shall find, me unafraid.     It matters not how strait the gate,     How charged with punishments the scroll,  I am the master of my fate: I am the captain of my soul.

  42. Sources: • The New Zealand Catholic Bioethics Center. Bioethical Issues: Bioethical Principles. <http://www.nathaniel.org.nz/?sid=27> • ETHICS IN MEDICINE   University of Washington School of Medicine <http://depts.washington.edu/bioethx/topics/dnr.html > • William Ernest Henley. Invictus. <http://www.bartleby.com/103/7.html>

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