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141109P - WORKSHOP 1: CASE DISCUSSIONs

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Presentation at a training program for family medicine resident s at the National Guard Madina 9-10 November 2014 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). M{H (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.


SCENARIO 1:
·        An 80-year fully conscious and competent old man with advanced incurable cancer needed palliative chemotherapy.
·        The family objected when the doctor wanted to obtain informed consent from the patient because that would involve disclosing the diagnosis which would make the patient very sad and depressed.
·        The family wanted to make the decision without informing the patient.
·        What should the doctor do? Provide your moral reasoning.

SCENARIO 2:
·        A 30-year old woman presented with classical signs of acute appendicitis.
·        He consented to an operation to open the abdomen and remove the inflamed appendix.
·        The surgeon found a previously undiagnosed ovarian cyst and decided to remove it.
·        The removal was a simple and safe procedure that would not increase the duration of the operation.
·        The head nurse refused because the patient had not given consent.
·        What should the surgeon do? Provide your moral reasoning.

SCENARIO 3:
·        A 90-year old in ICU with stage 4 widely metastasized cancer and multi-organ failure was told by the doctors that there was nothing they could do to reverse the course of the disease and that they could only provide symptomatic treatment.
·        He asked to be discharged to die at home. His children objected saying that he needed complex nursing that they could not provide at home.
·        What should the healthcare workers do? Provide your moral reasoning

SCENARIO 4:
·        The thoracic surgeon wanted to carry out a de-bulking operation to decrease lung cancer mass to enable the patient breathe easier and he told the patient of the high risk of death from hemorrhage.
·        The patient 85-year old patient was drowsy because of medication and was suspected of suffering from dementia.
·        The doctor was not sure whether the patient was capable of understanding the explanations given and making serious decisions about the operation and he had no relatives nearby.
·        What should the doctor do? Provide your moral reasoning.

SCENARIO 5:
·        A patient presented to the clinic with vague complaints in the abdomen and worries about cancer.
·        Physical examination and investigations revealed no pathology.
·        The doctor was angry with the patient for wasting clinic time when he was in good health. 
·        As the patient was leaving he told the doctor that his uncle had died the week before of stomach cancer. The doctor did not respond.
·        What should the doctor have done? Provide your moral reasoning.

SCENARIO 6:
·        A young man sent for pre-employment examination filled out a health questionnaire and mentioned no health problems at all.
·        Physical examination revealed a severely dislocated shoulder and an unhealed acromial fracture.
·        When asked about them he admitted that they caused him pain from time to time but that he was patient and did not care much about them.
·        What should the examining doctor report? Provide your moral reasoning.

SCENARIO 7:
·        An 80-year old diabetic man, whose son had died last year from transfusion of mismatched blood, was admitted to the same hospital for observation after falling at home.
·        He insisted that no procedure be done without written approval by his physician son whom he wanted to sit by his bedside all the time.
·        Nurses were inconvenienced by having to get written permission for routine monitoring of vital signs and insulin injections.
·        The nurses refused to comply to his wishes and he refused to cooperate leading to a stand-off.
·        What should the doctor in charge do? Provide your moral reasoning.

SCENARIO 8: 
·        A young neurosurgeon planned to operate on a patient with lumbar spinal injury that had a 5-10% chance of success.
·        He was perplexed about taking informed consent.
·        If he informed the patient that the operation could go wrong and result in paraplegia with a 90% chance the patient would refuse the operation.
·        If the operation was not carried out there was a 95% chance of further deterioration leading to paraplegia after a few months.
·        What should the neurosurgeon do? Provide your moral reasoning.

SCENARIO 9:
·        A 30-year old patient of multiple sclerosis had 5 years while in good health designated her husband as the decision maker.
·        When she lost consciousness the doctors needed a decision whether to put her on life support.
·        The husband who had by that remarried and lived in a separate house decided against life support because it would prolong her suffering.
·        Her father intervened and decided for life support because that would be in her best interests.
·        What should the healthcare workers do? Provide your moral reasoning.

SCENARIO 10:
·        A university professor with previous episodes of transient stroke had written a directive and had it witnessed that if he lost consciousness he would not like to be resuscitated.
·        Years later he was brought to the hospital unconscious from head injuries sustained in a car accident.
·        The doctors reading his directive in his shirt pocket decided not to resuscitate him but his wife insisted that he be resuscitated.
·        What is the right course of action by the doctors? Provide your moral reasoning.