Mr. Ip is 96-years old. He lives at home with his wife and has several children in Hong Kong. He has a history of tuberculosis and chronic obstructive pulmonary disease. Over the past year, he started developing difficulty swallowing. A brain scan found evidence of multiple small subcortical strokes. He has been admitted multiple times for recurrent aspiration pneumonias. While each episode was accompanied by periods of confusion and increased debility, his mind would eventually clear and he would talk with his family and friends about Chinese history, one of his favorite subjects.

These multiple hospitalizations had been uncomfortable experiences for Mr. Ip. He sometimes experienced intractable nausea and vomiting and had to lie in bed for days on end. He would ask to go home soon after each time he was admitted. After one of these hospitalizations, he told his wife and his children, "I've lived a long life. When it's my time to go, please do not allow the suffering to be prolonged. I want to go peacefully."

The doctors at the hospital had discussed Mr. Ip's high risk of recurrent aspirations and the speech therapist had recommended placing a feeding tube. His family, heeding Mr. Ip's words and wanting to prioritize his comfort, opted instead for careful hand feeding.

One day, Mr. Ip started choking during a meal and had very labored breathing. He was immediately brought by ambulance to the A&E. He was admitted to the medical ward for aspiration pneumonia. Despite being placed on a facemask with the maximum amount of oxygen delivered, Mr. Ip remained hypoxic and in shock. One of his children at his bedside who is a physician knew that his father was imminently dying. He communicated this to his mother and siblings. Sobbing, Mrs. Ip nodded her head.

The doctor on the medical ward, Dr. Mok, approached the family to explain the plan of starting IV antibiotics and IV fluids. Mrs. Ip replied, "No doctor. We don't want you to start those treatments. It is my husband's wish that he would be able to go peacefully when his time has come. He would not want this to be prolonged."

Dr. Mok, while in agreement that Mr. Ip is critically ill and will unlikely survive, felt very uncomfortable with his wife's request. She felt she had an obligation to give a course of antibiotics because she cannot be absolutely sure that it would not work. In her mind she wonders, should she withhold what is considered standard treatment because of the family's request?

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Themes: Patient Autonomy, life-sustaining treatment, nutrition and hydration, Antibiotics, family determination, goals of care

- Dr. Christopher Lum, Consultant Geriatrician, Shatin Hospital

The practice of medicine is as humanistic as it is scientific. Its scientific basis rests upon empirical research that controls all but one single factor. The humanistic aspects anchor on having a caring attitude, respecting individual judgment and choice, and acknowledging our limitations and uncertainties in medicine. Treating patients as a sum of individual diseases where each disease is treated linearly may not benefit patients. In reality, patients commonly have interacting comorbidities and deciding the best management requires looking at each patient holistically. In this case, Dr. Mok might have considered aspiration pneumonia in isolation as a “single disease” in deriving the use of antibiotics as the “standard” treatment. Saving Mr. Ip’s life by treating his pneumonia might have been considered the single most important surrogate marker of success that would benefit the patient. Background interacting conditions that should also be factored into his care including his COPD, multiple subcortical infarcts, swallowing difficulty, recurrent pneumonia and increasing debility were under-weighed if not overlooked. In the case of Mr. Ip, his subcortical infarcts and breathing-swallowing incoordination from his COPD, both irreversible, had led to recurrent aspiration pneumonia which would likely be his expected terminal event. Patient management should be considered in the context of interacting co-morbidities and their reversibility as well as the patient’s wishes and preferences.

Upon hearing the request from Mrs. Ip to withhold antibiotics, it is worthwhile for Dr. Mok to consider the following points:

1. What is the chance that Mr. Ip will survive if the antibiotic is given? Does it really cure him or prolong the dying process?
2. What will Mr. Ip experience during the process if the antibiotic is given? Will this experience be compatible with his expressed wish, or the contrary?
3. Is Mr. Ip’s expressed wish and choice consistent when he was sick and when he was well?
4. Would there be any legal repercussions for Dr. Mok and the medical team if antibiotics were withheld?
5. Mr. Ip did not complete an advance directive but expressed his wishes verbally to his family. Are his family’s words enough to be relied upon as evidence of Mr. Ip’s wishes?

As in the case of Mr. Ip, his family had honored his wish to prioritize his comfort when they opted for careful hand feeding and accepted the associated risk of recurrent aspirations. This expected event has precisely occurred. At this time, his clinical state suggested that he was approaching his terminal state. Though episodic antibiotic treatment may be useful in controlling sepsis initially, its frequent and intermittent use will likely to induce antibiotic resistant infections and fails at the end. Even if Mr. Ip survived this time, this “successful” antibiotic treatment would be at the expense of culminating intolerable, uncomfortable experiences in Mr. Ip’s worldview, and he had clearly expressed his wish not to prolong this suffering. This wish was consistently expressed even on good days when he was not under stress or acutely ill, thus likely a thoughtful decision. Repeated use of antibiotics against his wish will add unfavorable psychological on top of physical suffering to Mr. Ip.

Survival is often considered the ultimate benefit and death the most dreaded ending by many medical providers. While death is, and should be, an adverse patient outcome; it is not, and should not be, the only one outcome to be considered. Other outcomes such as disability and/or the loss of ability to participate in social activities may be viewed as more detrimental than death by patients. ¹ It is thus acceptable and legal to withhold any life-sustaining treatment (including antibiotics) if it is judged to do more harm than good to a patient, or if the treatment is futile. As a matter of fact, the International Code of Medical Ethics published by the World Medical Association (2017) has recently revised the statement that "the health" in general of a patient is now the doctor's first consideration from “the health and life" in the original declaration. This change highlights that survival is not the sole factor to be considered in assessing beneficence and maleficence in medical practice. This principle is also reflected in the Hospital Authority Guidelines on Life-sustaining Treatment in the Terminally ill (2015) that states, “It is not an appropriate goal of medicine to sustain life at all costs with no regard to its quality or the burdens of the treatment on the patient.”

In this era of defensive medicine, Dr. Mok may have concerns about liability if she withholds antibiotic treatment in the absence of a written advance directive (AD). It should be noted that while an AD document is preferred, it is not considered a necessity in the decision to withdraw or withhold life-sustaining treatment(s). The decision to treat / not to treat should take into account the patient’s wishes if he is conscious and cognitively sound. For a patient who is mentally incompetent, the decision should be made through consensus building between the medical team and the patient’s close relatives based on the best interests of the patient. The patient’s prior wishes and values would be important in deciding what is in his best interests. In the case of Mr. Ip, one of his children was a medical doctor and knew his father was imminently dying. He had communicated this to close family members including the patient’s wife and other siblings. It appeared that consensus had been reached among his family to respect Mr. Ip’s wish, and the decision was articulated by Mrs. Ip. To alleviate anxiety about carrying out this decision, Dr. Mok may ascertain from Mrs. Ip and other family members on their understanding of potential consequences of withholding antibiotic treatment, the patient’s personal values and beliefs, any previously expressed wishes, and whether all important family members share the same goal and management direction. When in doubt, opinion from the Clinical Ethics Committee can be sought.

References

¹Tsevat J, Cook EF, Green ML, Matchat DB, Dawson NV, Broste SK et al. Health values of the seriously ill. Ann Intern Med 1995; 12(7): 514-520.