I was so captivated when I ran into the blog: The Other Side of EMS. I like how he posted a scenario and then asked for others' opinions and thoughts on what they would do. I've kept hoping for a new post from him as I find these quite thought-provoking, but he hasn't written one like this since October. So I thought I'd throw one out there.
You have an 87 year-old widowed male with mild dementia. He has a history of manic-depression which is not currently being treated. On this admission, an MRI suggests he has pancreatic cancer. Due to his age and his dementia and the poor prognosis of the disease, his three children have decided not to treat the cancer. They enroll him in the palliative care program while they make arrangements for home hospice. The family has been adament with the doctors and the nurses that they do not want him to know that he has cancer nor do they want him to know that he may be dying. They site his history of mental illness as their reasoning. They are also worried that his manic-depression will recur if he hears such distressing news. In addition, due to his dementia they doubt he will rememeber that he has cancer even if he is told multiple times.
What do you do? Do you honor the family's wishes or tell the patient despite their stated preferences? Do you educate the family on the importance of open communication during the end of life or do you assume that part of their desire not to tell their father comes from their own discomfort with the prognosis and thus give them time to adjust? Do you stress the importance of giving their father the opportunity to find closure in his life? Do you feel confident assuring them that you will treat the manic-depression if it recurrs regardless of his understanding of his current prognosis - knowing this could happen after they go home when the patient is no longer under your care? Understanding that this diagnosis is new for them too, do you do nothing and simply hope that over time they will change their mind when they are ready? Do you agree that it's futile to tell him since he probably won't remember anyway? I'll say no more, I don't want to give away too many options, as I genuinely want to hear your thoughts.
But one more question: in the meantime, as you are deciding how to best handle the situation, what do you tell the patient when he directly asks you why he is in the hospital?
My post called should we let her know she's dying just hints at my opinion on this subject. But I would be quite interested in understanding your unadulterated opinions before I ellaborate on my own.
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I'm so sorry all the comments have disappeared. I'm reading this in 2010 and would love to be also reading the conversations you had in the Comments sections.
Anyway, in this case, I would request a psych consult to find out if the family members' reasoning for not telling the patient he's dying is indeed borne out by the patient's mental health situation. I'm not certain how much the psychologist could ethically tell the family after the consult, but the results as charted in the medical record could guide *your* professional decisions/actions.
I would also educate the family, as you mentioned. And I would get the chaplain involved, to help tease out what might be deeper and to help the family with anticipatory grief (since not wanting to face that might be what's deeper).
And if the patient asked me, I would answer his question(s), although not necessarily head-on at first. Or -- better yet -- I might respond by asking what he thinks is going on.
Thanks for this blog!
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