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.
Earlier today, the intern spoke to Mr. Whiteside and fully explained the diagnosis, prognosis with and without intervention, and the risks and benefits of operating and the patient seemed to understand. However, he refused to consent to the operation even though that decision will in all likelihood lead shortly to his death.
You are the resident currently in charge of his care. Your staff person has asked you to speak to Mr. Whiteside about having the operation.
CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^
YES NO The Candidate:
1. asks why patient does not want operation
(amputation) (e.g. "What's your
concern?").
----|-----------------------------------------------------------
2. asks about patient's mental/emotional
state (i.e. is patient depressed or
suicidal).
----|-----------------------------------------------------------
3. gives information about problem with leg
and ascertains that patient understands.
----|-----------------------------------------------------------
4. gives information about use of
prosthetic limbs following surgery.
----|-----------------------------------------------------------
5. ascertains that patient understands
consequences of decision (i.e. that he
may die without amputation).
----|-----------------------------------------------------------
6. asks about the presence of other
involved persons (e.g. family, children,
etc.).
----|-----------------------------------------------------------
7. agrees to respect patient's decision
(e.g. states that patient has right to
refuse operation, and/or that decision
to amputate is his).
----|-----------------------------------------------------------
8. asks if patient will consent to other
life-sustaining therapies (e.g. CPR,
antibiotics, etc.).
----|-----------------------------------------------------------
9. states that patient can change mind (but
only to a point, after which decision
becomes irreversible).
----|-----------------------------------------------------------
=================================================================
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
You are currently hospitalized with gangrene in your right foot and lower leg. Problems with your foot started three years ago, when you had an infection in a toe on your right foot which became gangrenous. It was discovered at that time that you were diabetic. The toe was amputated. Last year, you bruised your right leg while getting into a bus. The bruise developed into gangrene which resulted in an operation 6 months ago in which a portion of your right foot was amputated. At that time, an arterial bypass was done to decrease the likelihood that gangrene would recur. You went from the hospital to a rehabilitation centre, where you remained for 5 months. It was found that you had gangrene in the remainder of the foot and you were returned to the hospital last week.
You originally agreed to amputation of the leg, but you withdrew your consent on the morning scheduled for the operation. You were discharged and went to your daughter's home. After 3 days, you returned to the hospital.
You have discussed with some people the reasons for your decision: you have been unhappy since the death of your wife; you do not wish to be a burden to your children; you do not believe that the operation will cure you; you do not wish to live as an invalid or in a nursing home; you do not fear death (but welcome it as better than losing your leg and your independence).
You are discouraged by the failure of the earlier operations to stop the advance of the gangrene. You want to get well but are also resigned to death and are adamantly against the operation. Although a quiet and somewhat stoic person, you tend to be stubborn and somewhat irascible (especially when pressured). You are hostile to certain doctors. You are on occasion defensive and sometimes combative in your responses to questioning.
You are lucid on some matters and confused on others. Your train of thought sometimes wanders. Your conception of time is distorted. You do however exhibit a high degree of awareness and acuity when responding to questions concerning the proposed operation. You have made it clear that you do not wish to have the operation even though that decision will in all likelihood lead shortly to your death. You face the prospect of death with a despairing resignation as preferable to living as an invalid or in a nursing home.
You do not want to give the impression that you are deeply depressed. If asked, you might say: "There's nothing wrong with my spirits".
TIMELINE OF EVENTS:
46 years ago: married.
43, 41, 38, and 34 years ago: children born.
5 years ago: Retired.
3 years ago: Toe amputated, diabetes discovered.
2 years ago: Wife died.
1 year ago: Bruised your leg. (developed into gangrene)
6 months ago: Admitted to hospital. Part of right foot removed.
Arterial bypass done. Sent to rehabilitation
centre.
8 days ago: Admitted to hospital with gangrene in remainder of
foot and operation is scheduled. You withdrew
your consent on morning scheduled for operation.
4 days ago: Discharged. Daughter took you to stay with her in
her home.
1 day ago: Daughter brought you back to hospital.
Today: In hospital with gangrene in right leg and foot.
PROMPT 1 (immediately):
What do you want?
PROMPT 2 (by 1-2 minutes):
I don't want any operation.
PROMPT 3 (by 3-4 minutes):
It's my decision isn't it? Can you do anything without my
consent?
PROMPT 4 (by 5-6 minutes):
Are you going to do the surgery?
PROMPT 5 (by 7-8 minutes):
What's going to happen to me?