Dilemmas in Clinical Medicine, Sample Case Write-up

                                
                  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 patient who can not be consulted at the present time.

	This patient had raised intracranial pressure and would die 
without immediate treatment.  Being incapacitated, the highest 
standard for decision-making would be informed prior decisions 
when competent.[1]  This patient made some very specific statements 
about wanting only palliative care. The first question about 
these statement concern whether they were specific enough to 
count as the patient's own decision (rather than a substituted 
judgment).  Although the patient did not specifically address 
the issue of radiation to his head, he did refuse spine 
radiation in the past, even knowing that it might leave him 
paraplegic. I would argue that the patient made his wishes known 
in a way that applies to this decision as well.

	The second question is more difficult since it questions 
the authenticity of the patient’s statements.  No matter how 
specific these statements may be, they are suspect since they 
were (in retrospect), part of a carefully crafted scheme to 
obtain opioids.  Did they really represent the patient’s genuine 
feelings or were they hollow, manipulative words?  Although the 
patient was dishonest in explaining all of his actions and 
justifications, he did refuse radiation unequivocally and knowing 
the probable consequences.  That refusal underscores his intent 
to live with the outcome of his decision.

	Finally, the mother’s request that the patient NOT get 
aggressive treatment (but for a different reason) must be 
addressed.  This patient made life miserable for his mother 
during his years of addiction and she was weary of it. She still 
must be advised of the real reason for withholding radiation 
(his prior decision) rather than hers (it would not cure his 
addiction).  The patient should continue to receive palliative 
care only because this was his prior informed choice, with 
careful explanation and counseling provided to his mother.
The "right" decision for the wrong reason is really not right, 
but just coincidence.



Reference:
[1] New York State Task Force on Life and the Law. When Others 
Must Choose: Deciding for Patients Without Capacity, March 1992. 
Health Education Services, Albany. p.47-69