MGordon_MD
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Sep 6, 2011, 1:19 PM
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By Dr. Michael Gordon
It was another of my favourite activities – an ethics seminar with a group of health-care professionals who work in the geriatric department of a large Tel Aviv hospital.
Whenever I am in Israel, we meet to discuss a specific clinical case in which the staff is confronted with difficult ethical decisions, and we use the opportunity to talk about principles and approaches. With the requisite coffee, strudel and good humour, it is always an uplifting experience for me and gives me a chance to use my fractured Hebrew – which usually ends up with us collectively speaking “Heblish.”
The case we discussed could just as well have been from Canada: an older man living at home with severe dementia looked after primarily by his wife with the assistance of a personal-care worker. His two daughters helped with his care, and during the discussion it became clear that although they were not the legal substitute decision-makers, they seemed to be taking over that role from their mother, without her necessarily agreeing with their views.
The 92-year-old patient had been brought to emergency because of sudden onset back pain without any history of trauma. He was admitted to the geriatric unit, and tests revealed severe osteoporosis and a compression fracture of a lower vertebra. Another finding was a small tumour-like lung nodule that, from the X-ray, could not be determined as either benign or malignant. His significant dementia prevented his participation in discussions, but he was still able to eat and, with help, use the lavatory.
The daughters were pressuring the physicians to determine the “cause” of his back pain and nature of the lung lesion. The staff was reluctant to expose the patient to invasive investigations as those non-invasive ones already done (scans, CT scan, blood work) had not revealed further information. There was no one on the medical staff who thought that more tests would likely add to their ability to treat him, other than for symptom control. But they did think that determining whether the nodule in his lung was malignant, through bronchoscopy or needle biopsy, could lead to serious adverse reactions and was unlikely to prolong his life or comfort.
The daughters, despite their mother’s expressed reluctance, were pressing the doctors for “more information” to “know exactly” what was wrong with their father. The wife was reluctant to get into conflict with her children, but seemed to understand better the status of her husband with whom she lived, while her devoted daughters only visited, although regularly.
At the end of the team discussion with me, after exploring all the points, it was decided to ask the daughters what they thought more information would provide for their father, who was already on the steep trajectory slope of decline from dementia, which they clearly did not understand has a terminal phase. We agreed to stress to them the reality of his dementia illness and that his comfort during the limited period of life he had should be the focus now, rather than exposing him to the potentially negative impact of modern technological medicine.
I suggested that the team emphasize to the daughters, in a loving and supportive fashion, the limits of “more information,” when what their father needed at this point was love and devotion and a focus on comfort rather than a “diagnosis” that was unlikely to add much to his life.
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Dr. Michael Gordon is Medical Program Director, Palliative Care Baycrest Geriatric Health Care System in Toronto, Canada and Professor of Medicine, at the University of Toronto.
Dr. Gordon is the author of the engaging memoir Brooklyn Beginnings: A Geriatrician's Odyssey, published by I-Universe.
Brooklyn Beginnings is available in bookstores and online at: Indigo-Chapters, Amazon.ca, Amazon.com, Barnes and Noble and I-Universe
Moments That Matter: Cases in Ethical Eldercare: A Guide for Family Members, is available online at Amazon.ca.
His latest release is Late-Stage Dementia: providing comfort, compassion and care. It is available at Amazon and Indigo.
Visit Dr. Michael Gordon's website.
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