Physicians are practicing in an age of cognitive dissonance, doing much for fragile elderly patients in the short run, even if there is little they can do in the long run. In such a setting, how can one determine what counts as good care? I need some help, Dr. Niemira. I don't know what to do. The resident standing in front of me was not looking for medical advice. She was looking for ethical guidance in a situation she would encounter in a multitude of variations throughout her career as a primary physician--how one appropriately treats an incompetent elderly patient. As a caring physician, she had responded to a family's request to assume of their relative, who lived in a nursing home. She knew little of the family or the patient when she agreed to take on this responsibility. Her first encounter was an emergency call because of choking and cyanosis. She was quick to size up the medical situation. Here was an elderly woman confined to bed with contractures of her arms and legs. She was deaf and had limited interaction with her environment, although she seemed to recognize her niece and to respond to tactile stimulation. For several months she had had difficulty swallowing and an attempt at placing a percutaneous gastrostomy tube had failed. Review of the available medical records indicated previous unspecified gastrointestinal surgery, several small strokes, but no cancer or other terminal condition. There had also been problems with nasogastric tube placement, and family members wanted her to be fed orally despite periodic spells of aspiration. The incident that brought the resident to the nursing home appeared to be one more episode of aspiration in a chronically ill, debilitated patient with no known malignancy. While incompetent, this woman was clearly not unconscious or in a persistent vegetative state. As the resident cataloged the treatment options, she decided that aggressive therapy was not warranted and that care and comfort should be the treatment goal. The family concurred in this decision and expressed strong sentiments that the patient not be transferred to the hospital. The ethical dilemma arose as the resident attempted to translate care and comfort into concrete actions. Suctioning, changing of feeding routines and positions, using supplemental oxygen and analgesics if necessary were all part of basic care. But what about antibiotics to deal with the infectious pulmonary by-product of the situation? Should they be used in this case? She clearly felt antibiotics were indicated, but the family questioned their use, seeing it as an attempt to prolong the dying process. Was the use of antibiotics in this instance truly a moral dilemma? As I reviewed the medical indications with the resident, she insisted that they were clinically needed. She would not use medical grounds to escape from a practice she considered fundamentally unethical: the withholding of potentially beneficial treatment from an incompetent patient. The treatment that she proposed involved using an antibiotic that could be given as a single daily injection at the nursing home. It was not inordinately expensive. If if failed, she could allow the patient to die, feeling she had provided ordinary for a potentially reversible illness. She acknowledged that this patient had a chronic problem that was irreversible and that recurrent aspirations were likely. However, she did not feel that death was imminent or life so burdensome for this patient that such simple treatment should be denied. She had been asked by the family to be the patient's physician. She concurred with their decision that no aggressive measures were indicated. But the withholding of antibiotics in this situation, for her, crossed a fine line between allowing to die and causing to die. That others could argue about whether antibiotics were indicated was irrelevant. That the family could request they be withheld was likewise noncompelling. …
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Nov 1, 1994
Lesley Griffiths + 1
Open Access