Biomedical ethics and bedside communication is currently taught to medical students in a classroom mainly in the first two years. In residency it is not usually given a lot of attention. This is leading to a situation where a very basic part of daily patient interaction is not addressed. This leads to many complex problems in the hospital that lead to moral dilemmas and conflicts.
The idea needs to be reintroduced that medicine is very much an art. It is an applied science that needs mastery in communication. No two patients are the same and an in depth social history is equally as important as the latest NIH guidelines in managing a patient. Understanding of patients’ perspectives is more important than what we think we know about the patient’s condition. We as physicians need to listen more to the patient and know who the patient is before we can help them. This discussion will demonstrate some cases where evidence of bioethics training was missing.
A 47-year-old man was diagnosed with metastatic lung cancer. Within two weeks of diagnosis he was admitted with an acute abdomen and needed to have emergency abdominal surgery due to the cancer. He developed postoperative bowel delay and opted to be a DNR — do not resuscitate. When I visited him three days post operatively, her hemoglobin was anemic at 7.5grams/dl. I called the resident and asked him why the patient was not transfused with blood; I got the response “that patient is a DNR.”
The surgical team had decided that as a DNR, he did not need blood. At that point his post op recovery was not especially unusual. He had not been asked about a blood transfusion. Subsequently he was asked and got about six units of blood. His seventeen-year-old daughter was in a school out of state and it was important for him to stay alive for a few days to see her. He eventually went home about two weeks later very much cognitively intact signed into hospice.
In another instance, a 76-year-old Jehovah’s Witness developed hydrocephalus (a fluid collection in the brain). She became very unstable on her feet due to this. She had no family and had a history of a heart valve replacement. She consistently refused a shunt for her hydrocephalus because she did not want the risk of infection to her valve. She was content to live the rest of her life in a wheel chair. She was aware it was not a bloody operation and she would not require a transfusion. These facts she repeated quite coherently to multiple physicians. Their notes indicated that they disagreed with her reasoning as regards the shunt.
The patient was later discharge home without the shunt. It appeared that the hospital was making arrangements to get her a court appointed legal guardian at home solely based on her refusal. This patient already had good community support in the Jehovah’s Witness community. Involving bioethics resources would have made it easier to understand this patient and the unique social support systems that Jehovah’s witnesses have as well as their attitudes towards life and death.
In yet another case an 85-year-old lady was admitted with a diagnosis of congestive heart failure (CHF). She had been diagnosed clinically a year before with metastatic breast cancer and Stage 1V Lung cancer. In both cases she had refused biopsy to confirm the presence of cancer. She was wheelchair bound and said she wanted no surgery, invasive procedures or chemo or radiotherapy. She clearly and consistently stated she knew she had widespread cancer and was at peace with the outcome. However, she did not want hospice and wanted to be hospitalized for limited periods for heart failure. After three admissions for CHF over nine months, she had become belligerent, because despite clear documentation, she was persistently advised to undergo biopsy.
Bioethics cannot be standardized like beta-blockers for heart failure. However, history should inquire about values. Simple questions like “what is most important to you now apart from getting better” and “what is your most special wish” could be included into routine care. Such information may allow us to better understand and plan ahead. Bioethics properly taught and utilized will allow us to know that our patient will die happy if she sees her estranged child. Facilitating that may be more important and satisfying than the latest technology. I daresay that in a few cases early understanding of the patient will prevent some complex end of life decisions.
Bioethics should be more integrated into bedside medicine and not sidelined to academic discourse.
-Zakari Tata is a family physician.