Instructional Strategies – Case Study 1

In addition to lecture and reading assignments, the following case can be used for discussion or written assignments.

Case Sudy 1

Case Study of Mrs. P

Mr. Sharad Patel is an 82-year-old man with a history of:

• weight loss
• mild dementia

He is admitted to the hospital for an episode of bright red blood per rectum.

Further evaluation, including a colonoscopy reveals a large ulcerative mass in the colon and biopsy confirms colon cancer. Imaging reveals extensive local and hepatic metastasis. Patient’s functional status is declining as well.

The oncologist recommends palliative chemotherapy. You are a member of the primary health care team. Mr. Patel asks you questions about his condition and his prognosis. However, his son Ashwin (who is also his durable power of health attorney) as well as his wife, Mrs. Patel have already instructed everyone in the health care team NOT to tell the patient that he has cancer.

How would you respond to this difficult situation?

Topics for DiscussionDiscussion

It is not uncommon for older Asians to depend on the family to make medical decisions. Older Asian Indians are much more likely to subscribe to family centered decision rather than making these decisions by themselves.

This is a situation that requires sensitive handling. A clinician is legally and morally bound to answer all the patient’s questions with honesty. While the physician is obliged to exhibit primary loyalty to the patient, patients do not live in a vacuum. Typically, family members (especially the durable power of health attorney) are key stakeholders in the patient’s current and future well-being. Thus it is important for the physician to maintain an alliance with the family, while concurrently respecting the patient’s wishes.

This Specific Situation

Mr. Patel has mild dementia but there is no indication that he is not decisional. He has the right to know about his condition and the clinician is bound to answer them truthfully. The challenge in this situation is that the patient’s family does not what you to tell the truth to the patient. Requests like this are usually* an expression of love i.e. the family is fearful that the patient would suffer if he knew the truth and they are trying to protect the patient.

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One optimal approach to this problem is as follows:

Step 1: Tell the patient: “Mr. Patel, I know that you have a lot of questions. Your family members will also like have a lot of questions. I am going to gather all the accurate information and set up a meeting with you and your family to talk about this important issue.”
Step 2: Tell the family: “You are asking us not to discuss the illness with Mr. Patel. However, Mr. Patel wants to know what his illness is. Our primary duty is to our patients. We cannot legally or ethically withhold this information as it is the patient’s right to know. We would like to set up a family meeting and discuss with both you and the patient about his condition.”
Step 3: Hold a family meeting and discuss the situation.
If the family members vehemently insist that you still not tell the patient the truth:
Step 4: Meet with patient and family with at least 2 members of the inter-disciplinary team. Inform the patient and family about your primary obligation to the patient. Explain that the patient is asking questions about his illness and that the family is asking that you speak only to them. Then ask “Mr. Patel, your family is requesting that we discuss your health issues not with you, but just with them. You are understandably asking us questions about your disease. We are obligated to do what you ask us to do. How would you like us to handle this situation? Do you want to know the information about your illness or do you want us to talk to your family?”

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