- Costly Nutrition For A Terminal Patient The Patient Was A Forty Three Year Old Woman Who Had Seen A Doctor One And A Hal 1 (214.4 KiB) Viewed 16 times
Costly Nutrition for a Terminal Patient The patient was a forty-three-year-old woman who had seen a doctor one and a half years earlier because of vaginal bleeding between periods. At that time a standard workup was performed, including a fractional D&C. Tissue from her uterus was examined by a pathologist and found to be cancerous. The diagnosis was adenocarcinoma of the uterus, and the extent of disease based on clinical evidence was stage II. The patient received standard treatment, which began with external and intracavitary radiation. This was followed by surgical removal of her uterus, ovaries, and fallopian tubes and biopsies of appropriate lymph nodes. Examination of the dissected tissue revealed that the tumor had spread to the pelvic lymph nodes and the right ovary. In addition, there was tumor at the edge of the surgical specimen where the incision had been made through the upper part of the vagina. Because the cancer had spread to her vagina, a decision was made to also use chemotherapy. After six weeks the patient refused further chemotherapy, complaining that the drugs made her feel sick. She continued to obtain pain medication at the clinic where she had first received treatment but did not seek further chemotherapy. The cancer continued to grow, and one year after the initial diagnosis she went to the emergency room because of pain in her abdomen and vomiting. She was diagnosed as having a bowel obstruction from tumor compressing her intestines. The patient agreed to chemotherapy for shrinking the tumor before surgical correction of the bowel obstruction.... In order to provide nourishment, total parenteral nutrition (TPN, also known as hyperalimentation) was begun. This involves insertion of a catheter into the right subclavian vein, through which a liquid containing the total nutritional needs of the patient can be delivered directly into the bloodstream. The nutrient is a specially prepared solution containing specified proportions of protein, carbohydrates, fat, vitamins, and minerals. After three weeks of chemotherapy some medical problems arose which delayed surgery. ... [These problems were corrected. The surgery was performed, but then other complications occurred that required TPN to be started again.] Because of the grave nature of her illness, the patient arranged to be transferred to a distant city near her family. The patient was single, and her family included her mother, a twenty-six-year-old son, and a niece. ... Within a few days after admission, the attending physician decided that it might be appropriate to provide nutrition by some other means. The special nutrient solution used in TPN is very expensive, in this case costing approximately one hundred seventy-five dollars per day. In addition, the provision of TPN by central venous catheterization is a relatively invasive procedure which has risks of infection and septicemia. ... The physician recommended a gastrostomy, an operation to insert a feeding tube directly into the patient's stomach. ... [The patient agreed, but the procedure was cancelled after further complications arose that would make it ineffective.] The patient understood that her condition was terminal. Occasionally she was rather depressed over her illness and her separation from the out-of-state home where she had lived for twenty years. Whenever discussions turned to the fatal nature of her disease, she became tense and anxious. She maintained hope that God would cure her, which appeared to play an important role in her attempt to cope with the situation. Her physician suggested that she could either stay in the hospital or return to her mother's home, where care by a visiting hospice nurse could be arranged. She said she preferred to remain in the hospital because she could not manage her personal toilet by herself. Apparently, she felt it would invade her privacy too much to have her close relatives assist in her bodily hygiene. Another
question discussed was whether resuscitation should be performed if she suffered a cardiac arrest. The patient stated that she did not want to be resuscitated or have other "heroic" measures carried out in such circumstances. At that point the
question of continuing the TPN came to a head among the staff. One physician suggested that they discontinue it. He pointed out that TPN is a costly and sophisticated technology normally reserved for patients with a reasonable chance of recovery. Thus, it might be considered a "heroic" procedure in this case. Because the patient wanted no extraordinary means to sustain her life, he did not think it consistent to continue hyperalimentation. Note a few other facts of this case: The patient is in a public hospital and the taxpayers would ultimately pay any portion of her bill the patient could not cover. Also, related to rising health care costs, a recent report found that 22 percent of all Medicare expenditures are incurred for dying patients during the terminal phase of illness, although they only constitute only 5 percent of all Medicare patients. [Reference information = Ackerman and Strong. 1989. A Casebook of Medical Ethics. NY: Oxford University Press, 208-211.J
Case 2 4. Briefly explain what a utilitarian would do in this case. 5. Briefly explain what the doctor would do if he uses the principle of justice (worst off criteria).