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  #1  
Old 10-09-2012
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Medicolegal and Ethics Wife and Son disagree on Treatment

Ethics, concept from RX (I spent my lunch break thinking of it : )

84 man loses conscious after hospitalization and has many many severe health issues. After your evaluation you suspect bowel obstruction. Patient does not seem to gain consciousness. His 29y.o.-wife does not want you to do surgery, as she thinks that is what her husband would want for himself.
His 50y.o. son wants you to do everything possible to save his father.

What do you do?

a. surgery without consent
b. no surgery until pt gains consciousness
c. surgery after court order
d. hospice care.

=========
really sad situation if you are going to be next Hugh Hefner....
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the only point in favor of surgery is that the kid wants u to do everything u can do to treat his father. On the other hand, surgery has its own morbidity, & an 84 year old guy with multiple problems may not even survive the surgery, if we knew of his other comorbidities, we might be able to estimate surgical risk & make a better decision.
pt's wife thinks he might have not wanted to have a surgery, & spouse's opinion on what the pt wanted is more relevant, the spouse being closer, etc

a court order would be needed in a non-emergent situation where the physician has a different opinion than relatives regarding patient care

no surgery until pt gains consciousness doesnt make sense either way; if a surgery is justified, u gotta do it now coz bowel obstruction is an emergency. if its not justified, u dont do it even if the pt gains consciousness

that leaves us with hospice care D); which i dont want to select; but that does seem to be the right answer on the face value of the question
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Surgery is for bowel obstruction.
without this surgery he will die - guaranteed.

And lets assume that risks are minimal and benefits are - "life"
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Old 10-09-2012
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I don't know if this emergency or not !! The question is not very clear

If we assume that it is emergency = do the surgery anyway !

If we assume that it is not emergency = no advanced directive or living well = we have to ask family members = a spouse is more important than a son (According to Kaplan medical ethics) = don't do the surgery

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Quote:
Originally Posted by DocSikorski View Post
84 man loses conscious after hospitalization and has many many severe health issues. After your evaluation you suspect bowel obstruction. Patient does not seem to gain consciousness. His 29y.o.-wife does not want you to do surgery, as she thinks that is what her husband would want for himself.
His 50y.o. son wants you to do everything possible to save his father.

What do you do?

a.surgery without consent

b.no surgery until pt gains consciousness

c.surgery after court order

d.hospise care.
d.hospice care.
It doesn't matter how many co-morbidities he has but what he would have wanted which is what the wife conveys.
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Hospice care, his son can say whatever he wants but the one that can make decisions regardless of age or whatever is the next of kin.. which legally is THE PATIENT'S WIFE so if she says NO because she thinks thats what the patient would've wanted then thats what you do.

This dude can be his son but sharing blood doesnt mean you know that person well or that you have any opinion when there is a person that knew the patient better OR that legally has more power than you
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Quote:
Originally Posted by DocSikorski View Post
Surgery is for bowel obstruction.
without this surgery he will die - guaranteed.

And lets assume that risks are minimal and benefits are - "life"
if risks are minimal, then as there is no written or verbal advance directive, go with surgery

the question doesnt say whether the obstruction is complete or incomplete; it might be manageable with GI decompression, enema etc

the question has to be more specific to make a decision; with the limited data given in the question i think hospice care is the best option
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I think this is a great clear question actually, but the stuff is really twisted here.

The deal is - you do surgery - pt. lives... (no matter if he comes to consciousness or no, he lives)


You do not do surgery - he most likely to die (not right now, but sooner or later)

You cannot obtain a consent from him - so technically you cant operate.
Otherwise it is an assault.

You have to ask his proxy or living will.
Well in this case we have 2 proxies.
And by the US rules - wife is the best representation of what patient would most likely want.
Even if in this case she most likely wants him to die.


So in this case you cannot do surgery until he comes to consciousness...

Answer - B
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the question states that "Patient does not seem to gain consciousness."

it does not state that the patient has life-threatening complete obstruction. for all we know it could just resolve with an enema

plus, if u wait for pt to regain consciousness, he may never gain cosciousness. How long will u wait?
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Originally Posted by theundead View Post
the question states that "Patient does not seem to gain consciousness."

it does not state that the patient has life-threatening complete obstruction. for all we know it could just resolve with an enema

plus, if u wait for pt to regain consciousness, he may never gain cosciousness. How long will u wait?
no clue how long... just wait...
even for enema you need consent, but thats another question
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Quote:
Originally Posted by DocSikorski View Post
84 man loses conscious after hospitalization and has many many severe health issues. After your evaluation you suspect bowel obstruction. Patient does not seem to gain consciousness. His 29y.o.-wife does not want you to do surgery, as she thinks that is what her husband would want for himself.
His 50y.o. son wants you to do everything possible to save his father.
Good question. I fell right into the trap (Hospice care).
Wife doesn't want surgery but never said that she (as a proxy) doesn't want him be treated conservatively.
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It's more likely she wants him dead, thats why such a huge age difference in the question...

Thats why I answered myself to do surgery after court order...
but thats wrong too
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Why not A. Do surgury .

In case of emergency. Doctor has to take disition in best interest of the patient.
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Originally Posted by cingulate.gyrus View Post
Why not A. Do surgury .

In case of emergency. Doctor has to take disition in best interest of the patient.
This is not an emergency. It would be an emergency if his carotid/femoral/aortic bleed was painting the ceiling and no one was available to consent.
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Quote:
Originally Posted by DocSikorski View Post
It's more likely she wants him dead, thats why such a huge age difference in the question...

Thats why I answered myself to do surgery after court order...
but thats wrong too
It doesn't matter what her intentions are since he chose to marry her and therefore, by default, gave her this power. He wrote his fate that day

Surgery after court order is only chosen when there is no clear answer e.g. when wife is not there and different son/daughter/niece/nephew/dog/cat have different opinion of their own (as against "what the patient would have wanted"). Moreover, according to Conrad Fischer, it is never the right answer.
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