Disagreements over timing for advance care planning
Topic: Disagreements over timing for advance care planning
Case commentary and voice by: Dr. Derrick Au Kit Sing
Introduction: This video aims to discuss the clinical ethics case as a scenario of moral distress in which the healthcare professionals might be confronted with disagreements over timing for advance care planning.
00:11 Case description
05:58 Case commentary
06:20 How does the nurse Ms. Leung know that her suggestion is the right thing for the patient?
06:40 Was the doctor-in-charge Dr. Kam wrong?
07:22 Was the patient’s concern just about the BiPAP mask?
08:05 On moral distress
08:46 What can the nurse do?
09:21 Case commentary wrap up
Mr. Chau is a 75-year-old man who lives at home with his wife and his son's family. He was a former smoker and suffered from chronic obstructive pulmonary disease (COPD) for many years. Over the past year, he has become more easily short of breath with routine activities like walking around his home, dressing himself or taking a shower. He has also experienced more frequent exacerbations that led to several hospitalizations. In the last six months, he's already been admitted three times. Each time, he was put on a BiPAP machine for several days before his condition improved.
Last week, Mr. Chau was admitted again for another exacerbation of his COPD. After a week of treatment in the respiratory ward, he was finally able to come off the BiPAP mask. However, when the food tray was delivered to Mr. Chau, he pushed the food away. Ms. Leung, a registered nurse in the ward, saw this and recognized Mr. Chau from previous admissions. She approached Mr. Chau to ask why he didn't want the food.
Mr. Chau answered, "What's the point of eating? Just to keep coming back like this and be put on that mask? I'm as good as dead!"
Concerned, Ms. Leung asked Mr. Chau, "Is something wrong? I thought you'd be glad to come off the mask today."
Mr. Chau said, "Well, it's just temporary. I know how bad things are with my lungs. It's just a matter of time. I just don't want to go through the same ordeal over and over again, in and out of the hospital. Then one day, game over. If I'm going to die anyway, I don't want to be strapped to that mask up the final moment! You know how awful it is to be on the mask? You can't eat. You can't talk. It just blows air into your face!"
"It sounds like you're really concerned about being put on that mask again," Ms. Leung said.
"Yeah. I don't ever want to wear it again! Just let me go without making me suffer through all that! I've had enough!"
"Have you told your family how you feel?" asked Ms. Leung.
"I tried. But my wife and son...they won't listen. They don't want me to talk so negatively. They said that I should just listen to the doctor. The doctor barely even has time to talk to me!"
Feeling that Mr. Chau is probably correct about the advanced stage of his lung disease and that he's reasonable to prefer to be comfortable at this point, Ms. Leung decides to discuss Mr. Chau's concerns with Dr. Kam, the doctor-in-charge. She suggested that Dr. Kam should hold a family conference to explain his poor prognosis with his wife and son and to sign an advance directive for Mr. Chau.
However, Dr. Kam disagreed. "It's too premature to sign any advance directives and discuss end-of-life care issues. Mr. Chau's condition can still be relieved by the current treatments. He's ready for discharge soon!"
Ms. Leung felt powerless and does not know how she can help Mr. Chau.
Themes: advance care planning, advacnce directives, moral distress, life-sustaining treatment, conscientious objection
- Dr. Derrick Au Kit Sing, Director, CUHK Centre for Bioethics
We may discuss this case as a scenario of moral distress in which the nurse Ms. Leung felt powerless for being unable to do what she considered the right thing for the patient, as the doctor-in-charge held a strong opposite view on what was right.
Ms Leung's suggestion was to hold a family conference to explain the poor prognosis to the family, and to sign an advance directive for the patient.
Before considering her moral distress, it is useful to take a step back to ask a few questions:
How does Ms. Leung know that her suggestion is the right thing for the patient?
This may be a pragmatic approach to overcome a deadlock. One may argue that taking the pragmatic approach does not always work, and there may well be other scenarios where institutional constraint is undisputable and even unfair. In some circumstances, a healthcare professional may need to bring up the issue of concern to hospital management, or raise conscientious objection to unethical practice.
In this particular case, it would appear that there is room for further assessment of the patient, positive communication within the team, and dialogue with the patient's family.