Case Study 2

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

Case of Mr. M

Case Study 1Mr. M, a 76-year-old Pakistani male, is brought to the outpatient clinic for evaluation of gait unsteadiness. He has been diagnosed with renal cell cancer with metastases to the lungs. His wife passed away one year ago, and he had to move to America as all his children have settled here. He is a farmer from Punjab and only speaks Punjabi. A left hemiparesis is found during the examination and the internist wants to get a head CT to rule out brain metastases. His eldest son, who also serves as his translator, accompanies Mr. M and says that he is the primary decision maker for Mr. M. who confirms this statement.

The son takes the doctor aside and requests that she should not tell the patient about suspicion of brain metastases. He agrees with getting the head CT and obtaining a radiation oncology and oncology consult, but requests that all these doctors not mention the word “cancer in the brain.” They can discuss treatment without mentioning the word “cancer.” He thinks if his father knows about the cancer in the brain, he will give up the will to live.

The son still believes that his father will be cured of the cancer. In addition to the allopathic treatment, the family is also consulting with a spiritual healer in New York who has assured them that the cancer will be cured in six months.

The CT scan of the head shows a large brain mass on the right side causing cerebral edema and midline shift. The patient is started on oral corticosteroids and radiation therapy. The spiritual healer in New York has given Mr. M. and his son butter that is blessed by holy words, and they apply it to his head, lungs, and abdomen. Mr. M. develops dermatitis on the scalp, and is told by the radiation oncologist not to use this “hair oil”. The patient stops eating and drinking and becomes very weak and is admitted to the hospital.

Multiple attempts to address advance directives with the son have been unsuccessful. The son wishes his father to be a full code. He believes his father will be cured and it is in Allah’s hands. He gets angry with the doctors and thinks they just want to get rid of his father because they want to save money. The palliative care team in the hospital is consulted and they obtain a translator who is not related to the patient. The interview is conducted at a time when family is not present. During the interview, the patient starts to cry, and says multiple times that he wishes he were dead. He says he is so ashamed of the fact that he can’t walk and that his daughter-in-law has to help him get in and out of bed.

He is even more ashamed about the fecal and urinary incontinence and that his daughter -in-law has to see him naked and clean him. He says nothing can be worse than this. He does not want to go to New York, but he knows that his son still believes he can be cured and wants to go on. He does not want to share his thoughts with his family, as he does not want them to think of him as a weak person. He still defers all decisions regarding his health care to his oldest son, but wishes that the son would give up and face the reality that he is dying and let him die in peace.

Topics for Discussion

Discussion Topics:

1. Communication about the diagnosis

2. Autonomy vs. family decision making

3. Patient’s wishes vs. cultural norms

4. Advance directives