Autonomy and Informed Consents

[rncee]

below is a hypothetical situation given to us by our professor, until now im a bit confused regarding how far autonomy can go and informed consents as well..i hope someone can help me regarding this..

zenobia, age 80, live about 50 miles from a town with medical care. about a year ago, cancer of the colon was discovered. the physician who diagnosed the condition wanted to use chemotherapy, which he estimated had a 50 percent chance of bringing about a remission of several years in a woman her age. zenobia refuses treatment because the treatment is painful, expensive, involves trips to another town 100 miles distant. aside from the cancer, zenobia has excellent health for a woman of her age.

now, zenobia has been hospitalized with pneumonia. she is delirious when a neighbour brings her in. she has no children or relatives. she will die of cancer in few weeks.

is it medically indicated to treat pneumonia in an old woman dying of cancer? do her previous reasons for refusing treatment for cancer still hold since she is now actually in the hospital? in the absence of a family member, who has the right to make decisions about her treatment?

any help will be appreciated..thanks.. :)

[patwil73]

To answer your question, it is helpful to remember that autonomy is almost a fundamental principal of healthcare. People have the right to make their own decisions regarding what care they want and don't want. However, when you lose the capacity to make informed decisions, you also lose your autonomy.

In this case, the woman when she became delirious, lost her right to make her own decisions regarding care. Now if she had an advance directive written that would take over - since that is the purpose of them. In the absence of an advance directive, it would come down to whoever had the legal right to make decisions for her.

Without and family involvement, the first person to make decisions would be the doctor. If the patient happened to survive the night and still no family could be found, then the hospital would begin the process of getting her a guardianship that would make those decisions for her - unless she regained the ability to make her own decisions.

If the doctor knew of her prior wishes he might very well hold off on giving her chemo (he might also just because it could be useless at this stage), but in the absence of an advanced directive most physicians would probably treat her as full care - even knowing her wishes since to do otherwise could be a legal nightmare.

So yes it can be medically indicated to treat pnuemonia in someone dying of cancer - and it could prolong her life uncomfortably. This is why having an advanced directive available and family who understand and will support your wishes is so important.

Hope this helps

Pat

[miss81, BSN, RN]

I don't live in the US, so the "lawsuits" just aren't as big of an issue (I'm not naive, I know they still happen) . I know for sure that not one doctor at my hospital would order that chemo after knowing her wishes for sure. Even if the family wanted it, I'm sure they would have a fight on their hands. I've even seen a doc write a "NO CODE" on a pt that the family wanted "everything done." He said that he can make that decision without their consent because resuscitating that pt would be futile and cause more pain, suffering and harm. That decision totally put the Nurses in a terrible position....

[rncee]

Your answers are indeed true. Ethics can be a really complicated subject when it comes to real application on this kind of situations. thanks for all the help! i really appreciate it. :)

[mamamerlee, LPN]

Treating the acute situation is not the same as treating the chronic situation. Getting the temp and pnuemonia under control is not like giving chemo. The patient is entitled to the palliative care needed to here to make her comfortable. Even in hospice care, things like UTIs and pnuemonia still get treated.

[classicdame, MSN, EdD]

Certainly points out why Advanced Directives are nice to have. Personally, unless she had a directive I think she ought to be treated for the pneumonia and not cancer until, or if, she is alert enough to say otherwise.

[rncee]

thanks for all your answers! it really helped clearing out my mind..

Ethics can really be a confusing one, isn't it?

Again thanks to all of you! :)

[talaxandra]

Ethical issues can indeed be confusing.

My take: a year after diagnosis chemo is unlikely to be effective, and the reasons Zenobia decided against it (painful & expensive) are still valid. I think initiating chemo at this stage would be ineffective and contrary to her expressed, autonomous wishes.

Her delirium is mostly likely a result of the pneumonia - treatment is supportive and inexpensive. Zenobia has cancer but she's not necessarily dying of it - the pneumonia could be an indication that she's succumbing but at the age of 80 it could just as easily be unrelated to her diagnosis of colonic cancer. If she was previously well then IV antibiotics, hydration, O2 and rest should restore her usual mental functioning.

There is also a possibility that her delirium is due to an undiagnosed brain met, in which case the cancer has significantly advanced, and aplliative therapy may be more appropriate than treating the pneumonia.

[meluhn]

It is medically indicated to treat pneumonia, that is a comfort issue. She may still die of cancer but at least she won't suffer respiratory distress for weeks or days until she does. We never get consent to treat pneumonia anyway, we just do it. She never refused all tx, just chemo, and I cant say I blame her for that. The refusal of chemo still stands IMO.