This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.
The daughter, whom you are about to see, wants a Do Not Resuscitate order put on her mother's chart.
You are a doctor on the medical team that is looking after Mrs. Reed. Conduct a focussed and appropriate interview with the daughter.
CHECKLIST ITEMS:
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YES NO The Candidate:
1. asks about mother's mental status or
points out that mother is "alert",
"aware" etc.
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2. asks daughter if she has ever discussed
use of life-sustaining treatments with
her mother or is she knows what her
mother's preferences for life-sustaining
treatments are.
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3. states that mother's preferences might
differ from preferences of daughter or
preferences the daughter expects her
mother to have.
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4. states that it is the mother's right to
make this decision.
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5. states that the daughter would want to
be involved in a decision about her own
life. (e.g. Put yourself in that
situation. etc.)
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6. states that the mother may not be
frightened by, or may even welcome,
discussion of her illness and the DNR
order.
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7. states that the discussion can be
handled in a sensitive way.
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8. states that daughter may be present
during the discussion.
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9. refuses to write the DNR order without
the mother's consent.
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10. states that he/she would write the DNR
order with the mother's consent.
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RATE FROM 1-5:
+------------------------------------------------------------+
| | | | VERY | |
| POOR | FAIR | GOOD | GOOD | EXCELLENT |
| 1 | 2 | 3 | 4 | 5 |
+------------------------------------------------------------+
1. How would you rate the candidate's communication skills?
1 2 3 4 5
2. How would you rate the candidate's ability to address the
ethical issue in this case?
1 2 3 4 5
Your mother, Mrs. Joan Reed, is a 69 year old widow. She has a 10 year history of coronary heart disease ("heart problems"). She has been deteriorating over the last 4-5 years. (She has possibly been in chronic congestive heart failure for most of that time.) She is barely able to get around the house. Walking from the living room to kitchen can leave her short of breath. She's had a few previous heart attacks. You definitely know about one last year and one a month ago (although there may have been more). You suspect she had her first heart attack about 10 years ago.
A week ago she went into acute pulmonary edema. You happened to be visiting and called an ambulance which rushed her to the Emergency Department. She was intubated and ventilated and was admitted to the Intensive Care Unit (ICU). On day 3 in the ICU your mother went into ventricular fibrillation. She was successfully resuscitated. She is now on the ward, and she is awake, alert, and aware. Your understanding of DNR is that it's an order you put on the chart to stop them from sticking tubes in her and shocking her and that it would prevent a loved one from needlessly suffering.
Your agenda is that you want a Do Not Resuscitate (DNR) order put on your mother's chart and you don't want the doctor to discuss this with your mother. Your affect is subdued but serious. The motivation for this request is love for your mother. It saddens you greatly to see what has happened to her quality of life. You may be teary at times, but certainly not hysterical.
Your request is based on YOUR perception of the quality of your mother's life. The message you give is that YOU don't think her life is worth living as it is.
You may say things like:
"We know mum is getting worse. Her condition is really
deteriorating."
"Her mind is sharp as a tack, but her body is giving out.
The quality of her life has really gone downhill."
"She doesn't deserve to live like this. She deserves to
maintain her dignity."
I'm only asking this because I don't want someone I love to
suffer needlessly."
"Why would you go to unnecessary lengths to prolong
someone's suffering?"
"I'm in there with her every day now and it breaks my heart
to see her like this."
"I wouldn't want to live like this. Look at the life she's
leading."
"Seeing her treated like a piece of meat I can't bear
anymore."
"I would hope someone would do this for me if ever I got
into my mother's position."
If asked why you don't want your mother to know about the DNR
request, you may say things like:
"How can you talk to people about things like this?"
"I don't want to upset or scare her."
"Talking to her about how serious this is, is going to scare
her to death. She'll feel that we're abandoning her."
"I know she only has a little time left and I don't want to
make that time worse."
If asked what your mother thinks, you may say things like:
"I don't know what mom thinks. I don't feel too comfortable
asking her. I think she would want to spare me from these
bleak thoughts."
"I think she wouldn't want to go on living."
Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.
PROMPT 1 (immediately):
"I've heard there's something you can write on my mother's
chart so that she doesn't have to suffer anymore... so she
doesn't have to get shocked or have needles stuck in her
anymore. I really want to spare her further pain. Please
don't tell her I've asked you to do this. Can you just do
it without her knowing?"
PROMPT 2 (by 4-5 minutes):
"Are you going to do this?
PROMPT 3 (by 6-7 minutes):
"Why won't you do this for me?"
DON'T YIELD TO ANY ARGUMENT FOR THE FIRST 6 MINUTES (I.E. KEEP PUSHING FOR YOUR REQUEST). AFTER 6 MINUTES, IF THE CANDIDATE'S ARGUMENTS ARE GOOD, YOU CAN ACQUIESCE.