Case and Commentary
Jan 2005
A. Allowing Dr. Pandihar to assume complete care for Mrs. Scott is to be avoided. Dr. Lee's withdrawal from Mrs. Scott's care at this time may violate several of the Code's guidelines and cause her to feel abandoned and helpless. Opinion 8.11 "Neglect of Patient" prohibits neglecting patients once they have come under one's care. Opinions 2.21 "Euthanasia" and 2.211 "Physician-Assisted Suicide" caution physicians not to abandon patients once it has been determined that cure is impossible. Patients with terminal illnesses need multidisciplinary support; their primary physicians should not withdraw from participating in their care at this time.
B. Urging Dr. Parihar to acquiesce to Mrs. Scott's requests should be avoided; it is not supported by the Code. Opinion 2.037, "Medical Futility in End-of-Life Care" states: "Attempts should be made to negotiate disagreements if they arise, and to reach resolution within all parties' acceptable limits, with the assistance of consultants as appropriate." Moreover, Opinion 2.19 "Unnecessary Medical Services" states that "Physicians should not provide, prescribe, or seek compensation for services that they know are unnecessary."
C. Reiterating the reasons that surgery is not indicated is preferable. CodeOpinion 2.037, "Medical Futility in End-of-Life Care" states: "Joint decision-making should occur between patient or proxy and physician to the maximum extent possible...Attempts should be made to negotiate disagreements if they arise, and to reach resolution within all parties' acceptable limits, with the assistance of consultants as appropriate." Attempts to reach agreement may well start by further explaining to Mrs. Scott the reasons why surgery will not achieve the medical goal she desires.
D. Asking Mrs. Scott to discuss why she wants surgery is acceptable and is supported by the Code in Opinion 2.037, "Medical Futility in End-of-Life Care," which states: "Joint decision-making should occur between patient or proxy and physician to the maximum extent possible...Attempts should be made to negotiate disagreements if they arise, and to reach resolution within all parties' acceptable limits, with the assistance of consultants as appropriate." Giving Mrs. Scott the opportunity to express the motivations for her wishes is one step in the process in joint decision-making and should provide an opportunity to negotiate the existing disagreement.
E. Suggesting to Mrs. Scott that she should seek transfer to another hospital may be supported by the Code, but, at this point, should be avoided. Opinion 2.037, "Medical Futility in End-of-Life Care" states that "If the process [of negotiating disagreements about futile care] supports the physician's position and the patient/proxy remains unpersuaded, transfer to another institution may be sought and, if done, should be supported by the transferring and receiving institution." It is still too early, however, in the process of discussing her request for an apparently futile surgery to warrant transfer to another institution.
