I feel there are many unknown factors with this case. Did the nurse tell the doctor that the patient had whispered her worries about the surgery and not entirely wanting to follow through with it? Did Esther mean to include the 'no surgery' in her living will? If so, does it still apply even though the gangrene was not related to the pancreatic cancer with which she was originally diagnosed? Given the information in the case, the situation could go either way. On one hand, her will never stated specifically that she did not want surgery. If the nurse never had mentioned the patient's uncertainty over the surgical procedure to the doctor, the doctor may never have known about Esther's worries. The surgery was not to keep her alive in the moment so to speak, but to prevent her from dying in the future. Also, the gangrene was not related to the pancreatic cancer. From this perspective, I could see why Dr. P would want her to have the surgery. Having said this, I believe it was wrong of the doctor to not have had consent of the family, being that the patient was confused. The doctor was aware of the patient's mental status, and therefore should have sought out more information or insight from Esther's family. My feelings toward this side of the situation would intensify if the nurse had in fact informed Dr. P of the patient's uncertainty toward the surgery. I do not believe it is right for a physician to take it upon themselves to make the decision for a confused patient's surgery, no matter the situation.
In the living will in question Mrs. K specifies against extraordinary means such as using chemotherapy, respirators, and resuscitation efforts in order to prolong her life, in her living will though she made no mention of surgery being used. However, considering that she expressed in her living will that she didn’t want any extraordinary means used to prolong her life I don’t feel she should have to specify every last specific way it could happen. I do however think it merits the discussion of bringing in her power of attorney to decide if that’s what she would have wanted or not. I would think anytime you’d see confused state in the chart of someone with a living will you’d not only want to meet with them but their family and whoever their power of attorney may be before deciding their consent was enough to go through with surgery, especially when it could violate their previously stated wishes. Without consulting them that’s definitely leaving the physician open to talk of him assuming consent just because it works with what he wants to do. Considering the fact the patient is in a confused state I think the family should have weight some in the judgment of whether or not the patient should undergo the surgery because the patient isn’t herself right now.
Situations like this prove to be very difficult for making executive decisions. I think that since Esther K wrote her living will well in advance, when she was full competent that the will should be followed. Situations like this greatly decrease the importance of having a living will because patients worry that it will just be overwritten by another doctor or family member. I agree with Brittany that the situation could go either way and that there is still a lot of unknown information; however when in doubt the living will of the patient should be carried out. The doctor should have consented with the family in this case because they could have spoken on Esther's behalf better than a doctor who probably knew very little of her. Knowing that Esther was very clear in her living will not to have any extraordinary means to prolong her life, she most likely was clear and confident in her decision and sharing it with her family. I believe the weight of the family's judgment should be weighed much higher in this situation because the patient was confused and the living will was updated and accurate to her wishes.
This is a very difficult case in the light that like Brittany said there are so many unknown factors that could push the case one way or another. I believe that having surgery on your foot for gangrene is not an extaordinary means used to prolong her life. While the surgery did probably save Esther from developing sepsis, if the doctor were to leave the necrotic tissue alone, it could cause sever pain that would have to be managed and many other symptoms that would have to managed by health care as well. We do not know if Esther would have wanted to be dedicated to a pain management schedule, or if she would have wanted to have a raging infection in her body. I believe that the doctor should have talked to the family before hand to discuss Esther's wishes and compare them to her living will. This is only being respectful in my book. I also believe that the family's judgment should be taken into consideration rather than the doctor's judgment. Like Lindsay said, the family knows more about Esther than the doctor does, and can relate to her wishes in a more accurate manner as well. I feel very sorry for Mrs. K, in the fact that she only agreed to the surgery due to fear of her doctor. No patient should feel like they are being forced to do something, much less forced to do it out of fear. It was probably very difficult for Mrs. K to express her fears due to her confused state. I wish there would have been some way that the patient could have let a nurse or another doctor know how she felt about the situation, because then this scenario could have taken a different route.
I agree with Melissa in that the doctor should definitely discussed surgery with Esther's power of attorney before proceeding with surgery because of her confused state. I also agree with Camille, because in my opinion, surgery to amputate a gangrenous foot is not extraordinary measures, especially considering that the gangrene was not related to the pancreatic cancer. I think that the point of Esther's living will was to insure that she would not suffer and that she would be allowed to die when her time came. As Camille said, gangrene will lead to sepsis, at which point Esther will most definitely suffer. It is unfortunate that it was not specified in Esther's will about surgery, because it is obvious that Esther is not in a fit state to make these decisions for herself. In this case, the doctor should look to the power of attorney for the ultimate decision in what happens in regards to Esther's care, but he should also be sure to explain to the family the suffering that will follow if Esther does not have this surgery.
Everything in today’s society is becoming one big legal issue. The case states that Esther did not any extraordinary means of saving her life, and she specifically referred to chemotherapy, respirators, or resuscitation. There is a loophole and a questioning of a definition. The definition being “extraordinary means” and a vision of the special Olympics popped into my mind. We have a huge event dedicated to people missing limbs and other conditions and we perceive that as normal. What you don’t see is society thinking about living off of respirators being a normal everyday thing. So does extraordinary pertain to losing a foot? Even though surgery was required, is it extraordinary that a foot was taken off to prevent sepsis of her whole body? Also, the doctor’s butt can be covered because Esther did not state that she wanted to keep her foot. So therefore the doctor asked the patient (whether or not the patient was able to comprehend the situation is next) and she agreed. From the physician’s standpoint, he assumes that if the patient does get out of the hospital, she will die from the gangrene, and therefore by amputating the foot, (if she goes home) she could live a normal life. But I do think the fact that the nurse did not communicate (or the nurse did but the physician didn’t listen) presents a problem, because if Esther wasn’t able to think clearly, the doctor may not have done what the patient wanted to do, not to say that the family could make that decision either on the account of Ester is the only person that can decide whether or not she wants to die from an infection rather than her disease. Therefore I don’t think that the family has a claim on injustice because the doctor was providing the best care that he could for the patient, even though it was through a loophole.
Scotty makes a good point about what is "extraordinary" in todays medicine. A decade ago the complex, expensive, high-tech treatments that are now commonplace and hardly "extraordinary." were seen as extraordinary. Feeding tubes were seen as an extraordinary means to extending life and now they are very common place in hospitals. I think that the use of the life staining medical equipment is more important then the actually equipment. I.E. a feeding tube for a patient who is recovering from a major surgery would not be seen as extraordinary, like a feeding tube for a terminal ill patient at the last stage of life. Another example would be a respirator/ventilator. It would be highly appropriate for a person fighting pneumonia but considered extraordinary for a person who is in a coma two weeks after a cardiac arrest.
I think in Esther's living will she may have said she didn't want to be helped in extraordinary means such as using chemotherapy, respirators, and resuscitation efforts in order to prolong her life, but she never really stated if she wanted surgery if something like gangrene was to happen and if she was not conscious enough to reply. I also agree with both Camille and Marion when they talk about different types of surgeries that use to be possibly life threatening or being a hard procedure isn’t anymore. I also believe that the doctor should have consulted with Esther’s family members before he made the final decision. I have the same opinion as Lindsay has when the family members may have known more about Esther than the doctor ever knew even if the doctor didn’t think they would. I feel like it would have been nice to have brought the family in this major decision. Overall, I feel like in this situation that it was very sudden and many emotions were put into play like Mrs. K’s fear of the doctor and of the family members not wanting to have the Doctor help anymore. I feel like this could be a problem with many other hospital situations and not just this one.
I have to agree with Christy and Scott because surgery doesn't fit into Esther's catergory of "extradordinary means" to prolong her life. She was specific when saying she didn't want chemotherapy, respirators, or resusitation efforts. So, technically the doctor did go by her living will. However, I think the nurse should have mentioned Esther's fear because then he could have seen that she is not fully herself, and then he could have discussed the decision with the family because they do know her best. Even though the family is upset, they knew that Esther was not herself, and they did not contact her power of attorney to make the decision for her. So, yes the family should have been involved in the decision with the surgery, but since the doctor was going off what he saw, (as Esther being in the right state of mind) they didn't have to be involved with the decision. Like Scott said, the doctor was just doing what was best for his patient.
i believe it is very important for everybody to have a living will. With having this living will it should specify the things they want and do not want to happen. i think if at all possible the person preparing the will should discuss it with someone they trust - an attorney or family member, as well as their doctor. This case stresses the importance of this, but ultimately with a living will it should be the patient's decision, if capable of making choices. Fear of living or dying by the patient should never affect the ultimate decision of choicing treatment. In this situation, the will is not specific enough to say whether she wanted surgery or not. Also, the gangrene has no relation to the cancer so i believe the doctor should go through with the surgery.
I have to agree with most of the post above. There is not a clear cut answer. Since Esther K wrote a living will I think it should be followed. Now that she is in a confused state, if the living will does not clarify for this kind of situation, I think the doctors should consult her power of attorney. I also believe like many others that amputating her leg would not be "extraordinary means." Yes eventually it could take over her whole body and she could die but it is not related to the pancreatic cancer. It is hard when the patient has a contradicting view when they are at the end of life. They may not be fully autonomous now but they still can feel emotions. I agree with many others about the fear factor. With Esther K approaching the end of her life, I believe she may have some fear and that can impact her decision. I think the doctors should maybe talk to Esther and her family together and see what they all think is the right thing to do. They may not all agree what is the right thing but hopefully that can make the best decision for the well-being of Esther.
So, Esther K has had a long history of diabetes and was diagnosed with pancreatic cancer. She then wrote her will refuting any kind of "extraordinary means" therapies that might be associated with her condition. It is not clear if she was competent at the time of writing this Will? After the diagnosis 'she was admitted in the hospital in a confused state....the Surgeon had no alternative but to help find the means of preventing the spread of the necrosis. again so many questions arises as to whether Esther K whispered to the nurse about her consent with regard to the surgery? A living Will to be considered morally decisive it must have been written while the owner is competent and also in the presence of witnesses and attorney for legal purposes. It's hard to determine how specific it should be because it is the owner's wish and desire for how things should be/go. There is a danger in assuming that a consent is valid merely because it coincides with what the physician wishes to do because based on the principle of autonomy, it is paramount to be respectful of the patient's will, and consent as well as the physician's and try to weigh the two. the surgeon's suggestion for amputating Esther K's leg would help prevent the spread of the gangrene. The family's judgment is based on the Will of their loved one and her wishes. They should be able to listen to the doctors suggestions and reasons behind his suggestions. I think since Esther was already in a confused state, the doctor should have talked to her family as well before proceeding with the procedures. Otherwise, to most extent I understand the family's fury since they were not part of the decision making and their loved one was already in a confused state...
I think the will should be specific enough to where you don't have questions, does surgery fall under extraordinary means? If these types of questions are popping up, then maybe they should describe to the patient what possibilities of treatment and life prolonging procedures are available, and then ask which falls under what category or what the patient would not want. I think there is a danger in assuming about valid consent. Like in this case, the doctor wants to amputate the foot, due to the patient's consent, but the patient was in a confused state. The doctor needs to assess the patient to see if she is able to make that sort of decision, especially since her will states something like no extraordinary means. The majority of the weight should be given to the family. Afterall, they know the patient best and what the patient would want. I also think the family has a right to be angry at the doctor. They were not asked about the decision when they should have been since they're loved one was in a confused state. I will say it's weird that the patient was worried the doctor would not take care of her, when she specified she didn't want extraordinary means, chemo, respirators/resuscitation, or aggressive therapies to prolong her life. Just what did she want the doctor to do then?
I think a living will should be very specific for it to be morally decisive. Doctors will do what is best for the patient unless the will or POA says otherwise. The doctor/surgeon should have taken into consideration the fact that Esther was confused and should have perhaps asked a family member or else view her surgery as extraordinary means. If Esther was scared that the doctor would no longer take care of her because of her decision against the surgery, why would she make a living will explaining not to do extraordinary measures? No patient should be scared that a doctor will not take care of them because of their decisions. Every patient has the right to say yes or no to a doctor. There is a danger in assuming that a consent is valid because it coincides with what the physician wants to do. If ester was really confused and the doctor went ahead and did the surgery, that could ruin esther for the rest of her life. He is going against her dignity in deciding that it is the right thing to do when she is not in the right state of mind. I do not think this could really happen. If there is a decrease in the level of consciousness, the surgeon will usually consent a family member if applicable. If Esther put her family in the will or picked a POA then the family should have a major input of the surgery. But, if Esther did not, then their opinion does not really matter, no matter how much they want it to.
I think a living will should be very specific to be morally decisive. When it comes to wills things become sketchy because the doctor wants to do want is best for the patient and different things can go wrong that requires the patient to be more specific on the will. Although the general public does not know everything that can or may happen to them. I think there is danger assuming a consent is valid. The patient could change her mind down the road and in this case surgery was not necessairly part of that will and the patient was confused when ahe agreed to the surgery. There should a great deal of weight given to the family because the patient was confused. If the patient was not confused and was competent then the family would not have a say either in the situation.
I think that the surgery did indeed go to "extraordinary means". What I wonder is if the nurse did indeed tell the doctor what Esther had whispered and if the doctor did know about the living will. If he did, then I believe he completely ignored her wishes. I do think that a living will needs to be specific and even put down examples. Esters specified "extraordinary means" which was good because it gave concrete examples of what she did not want. Esther's family should have been called in on the situation because she was brought in while in a confused state. They should have been notified before the surgery happened.
I feel that in this specific case, the patient's living will described what she did not want and surgery was not one of those things. A living will should always be very specific, so that wishes can be fulfilled properly. The physician should have assessed the patient's level of confusion better, but also the nurse should have been a better patient advocate and went to the doctor after the patient whispered to her. The nurse had a responsibility at that point to tell the physician what happened and how she felt about the patient's level of confusion. When the family decided that the surgery would have been against what the patient's will said, the staff should have looked into the matter. Since the will does not say anything about not doing surgeries, then I don't feel the physician was doing anything wrong. When a patient signs a DNR form, the physician doesn't stop care, so why would they not perform a surgery because the patient doesn't want to resuscitation, chemo, or put on a respirator?
A living will must be as specific as possible. With diabetes and pancreatic cancer, there are many things that could go wrong, so the will needs to cover as many scenarios as possible. Esther K should have let the doctor or family know what she wanted to do if found in a confused state. If they had known this, there might not have been second guesses. There could be a danger in assuming that a consent is valid because it is what the physician wants to do. Patients may change their minds according to the situation or state they are in. The physician and patient may discuss what is best in many situations, but in Esther's case, it was not decided what she wished to do if she became confused. I think the doctor over stepped the boundaries in this situation and should have stayed with her wish of not wanting any "extraordinary means". Obviously the family would know the patient better than the doctor because of other decisions made in the patient's life. Living wills can be uncomfortable to talk about, but then your family would know your wishes if anythings sudden should arise.
like many other post, i believe that the doctor did follow the will because it never said anything about surgery. She was specific in what she did not want and surgery was not in that. The doctor did prevent the gangrene from spreading which may have saved her life. I agree with Julie in that a living will should be as specific as possibe in order for everyone to understand what it is that you exactly want. Therefore, i believe that the family should not get so upset about the situation that happened.
Because the patient was not in a stable mental state, the surgeon is NOT ALLOWED to take this as the consent needed to do the surgery. The pt was not able to understand the risks and benefits of the surgery, the reason its needed, and the possible complications of the surgery. This is illegal. You are not allowed to consider a patient who is confused as a potential surgical candidate, unless they have an appointed POA who can weigh the risks and benefits for the patient.
Regardless of the patient whispering anything to the nurse, the legal documentation is what is important. If the MD deemed her to be competent enough to make the decision, he would have to obtain a psych consult to evaluate her decision making capabilities. In this case, it may be up to the family or POA because it is not likely that she will be able to legally give informed consent, which is required before surgery.
With that being said, the physician must treat any patient, even if they refuse surgery. They should be focused on symptom management at this point, if the family decides not to put her through surgery.
As said in many posts, I think that the family was wrong in saying that surgery is an extraordinary mean. Esther K was very specific in her definition of extraordinary means, surgery was not included in that. However, I think that if Mrs. K was confused when the doctor was explaining the situation of surgery to her, that he should have talked to the family or a lawyer representing her. If she was not in the correct state of mind to understand what was happening, someone should have been there to represent her.
In this case of the Living Will, Ester's will was precicely outlined stating she did not want chemotherapy, respirators, or resuscitation effects. Surgery to remove her gangrene does not fall into any of those categories. Therefore the surgery was ok to perform. As for the consent, if Ester was confused then she could not consent to surgery. Therefore the family would have the right to be upset. In this case the Doctor should have explained to the family the situation and had a legal representative for the patient make the decision for the surgery. All-in-all though no harm acompanied the surgery and the surgery made the patient more comfortable in the long term.
It is impossible for someone to cover every potential "what-if" scenario in a living will. By giving examples of what Esther considered "extraordinary measures" (i.e. chemotherapy, respirators), she implied what would be too invasive for her. Based on this evidence alone, I think that the doctor did the wrong thing by amputating Esther's foot. My interpretation of her living will is that she does not want any invasive treatments, even if they are trying to stop a disease that will take her life if it goes unchecked. Doing surgery likely prevented her from developing a secondary infection that would have killed her. But because she stated that she doesn't want invasive treatments, I think this overstepped the line. How is letting her die from gangrene and giving her pain medication to make her comfortable any different than letting her die of cancer (another disease which gradually destroys the body) and treating her in a similar way?
The physician had an obligation to his patient to not only explain the pros and cons of a surgical procedure, but also to listen to her concerns and determine whether she was competent to make the call. Based on Esther's comments to the nurse, I do not think that she was in the state of mind necessary to make such a decision. Because of this, I feel the doctor should have contacted her family so they could discuss the situation with him. The family, then, has an obligation to carry out Esther's living will to the best of their abilities, and not to make choices to benefit themselves.
For a will to be morally decisive it should be extremely specific and detailed. In this case it should say she doesnt want any "extraordinary means" to prolong her life while losing to cancer. There is a danger assuming that the consent is valid because the pt is clearly in a confused state. If she doesnt want it then there could be legal issues that result but if he doesnt do it then she could suffer and the possible time she did have left could be taken from her and that could be seen as morally wrong. Very little weight should be given to the family's judgement because the family may have a motive that requires the death of Esther and Esthers life should be left in her hands if she is still alert and able to make somewhat legitmate decisions especially when it comes to stopping something that is separate from the cancer.
I feel there are many unknown factors with this case. Did the nurse tell the doctor that the patient had whispered her worries about the surgery and not entirely wanting to follow through with it? Did Esther mean to include the 'no surgery' in her living will? If so, does it still apply even though the gangrene was not related to the pancreatic cancer with which she was originally diagnosed?
ReplyDeleteGiven the information in the case, the situation could go either way. On one hand, her will never stated specifically that she did not want surgery. If the nurse never had mentioned the patient's uncertainty over the surgical procedure to the doctor, the doctor may never have known about Esther's worries. The surgery was not to keep her alive in the moment so to speak, but to prevent her from dying in the future. Also, the gangrene was not related to the pancreatic cancer. From this perspective, I could see why Dr. P would want her to have the surgery.
Having said this, I believe it was wrong of the doctor to not have had consent of the family, being that the patient was confused. The doctor was aware of the patient's mental status, and therefore should have sought out more information or insight from Esther's family. My feelings toward this side of the situation would intensify if the nurse had in fact informed Dr. P of the patient's uncertainty toward the surgery. I do not believe it is right for a physician to take it upon themselves to make the decision for a confused patient's surgery, no matter the situation.
In the living will in question Mrs. K specifies against extraordinary means such as using chemotherapy, respirators, and resuscitation efforts in order to prolong her life, in her living will though she made no mention of surgery being used. However, considering that she expressed in her living will that she didn’t want any extraordinary means used to prolong her life I don’t feel she should have to specify every last specific way it could happen. I do however think it merits the discussion of bringing in her power of attorney to decide if that’s what she would have wanted or not.
ReplyDeleteI would think anytime you’d see confused state in the chart of someone with a living will you’d not only want to meet with them but their family and whoever their power of attorney may be before deciding their consent was enough to go through with surgery, especially when it could violate their previously stated wishes. Without consulting them that’s definitely leaving the physician open to talk of him assuming consent just because it works with what he wants to do.
Considering the fact the patient is in a confused state I think the family should have weight some in the judgment of whether or not the patient should undergo the surgery because the patient isn’t herself right now.
Situations like this prove to be very difficult for making executive decisions. I think that since Esther K wrote her living will well in advance, when she was full competent that the will should be followed. Situations like this greatly decrease the importance of having a living will because patients worry that it will just be overwritten by another doctor or family member. I agree with Brittany that the situation could go either way and that there is still a lot of unknown information; however when in doubt the living will of the patient should be carried out. The doctor should have consented with the family in this case because they could have spoken on Esther's behalf better than a doctor who probably knew very little of her. Knowing that Esther was very clear in her living will not to have any extraordinary means to prolong her life, she most likely was clear and confident in her decision and sharing it with her family. I believe the weight of the family's judgment should be weighed much higher in this situation because the patient was confused and the living will was updated and accurate to her wishes.
ReplyDeleteThis is a very difficult case in the light that like Brittany said there are so many unknown factors that could push the case one way or another. I believe that having surgery on your foot for gangrene is not an extaordinary means used to prolong her life. While the surgery did probably save Esther from developing sepsis, if the doctor were to leave the necrotic tissue alone, it could cause sever pain that would have to be managed and many other symptoms that would have to managed by health care as well. We do not know if Esther would have wanted to be dedicated to a pain management schedule, or if she would have wanted to have a raging infection in her body. I believe that the doctor should have talked to the family before hand to discuss Esther's wishes and compare them to her living will. This is only being respectful in my book. I also believe that the family's judgment should be taken into consideration rather than the doctor's judgment. Like Lindsay said, the family knows more about Esther than the doctor does, and can relate to her wishes in a more accurate manner as well. I feel very sorry for Mrs. K, in the fact that she only agreed to the surgery due to fear of her doctor. No patient should feel like they are being forced to do something, much less forced to do it out of fear. It was probably very difficult for Mrs. K to express her fears due to her confused state. I wish there would have been some way that the patient could have let a nurse or another doctor know how she felt about the situation, because then this scenario could have taken a different route.
ReplyDeleteI agree with Melissa in that the doctor should definitely discussed surgery with Esther's power of attorney before proceeding with surgery because of her confused state. I also agree with Camille, because in my opinion, surgery to amputate a gangrenous foot is not extraordinary measures, especially considering that the gangrene was not related to the pancreatic cancer. I think that the point of Esther's living will was to insure that she would not suffer and that she would be allowed to die when her time came. As Camille said, gangrene will lead to sepsis, at which point Esther will most definitely suffer. It is unfortunate that it was not specified in Esther's will about surgery, because it is obvious that Esther is not in a fit state to make these decisions for herself. In this case, the doctor should look to the power of attorney for the ultimate decision in what happens in regards to Esther's care, but he should also be sure to explain to the family the suffering that will follow if Esther does not have this surgery.
ReplyDeleteEverything in today’s society is becoming one big legal issue. The case states that Esther did not any extraordinary means of saving her life, and she specifically referred to chemotherapy, respirators, or resuscitation. There is a loophole and a questioning of a definition. The definition being “extraordinary means” and a vision of the special Olympics popped into my mind. We have a huge event dedicated to people missing limbs and other conditions and we perceive that as normal. What you don’t see is society thinking about living off of respirators being a normal everyday thing. So does extraordinary pertain to losing a foot? Even though surgery was required, is it extraordinary that a foot was taken off to prevent sepsis of her whole body? Also, the doctor’s butt can be covered because Esther did not state that she wanted to keep her foot. So therefore the doctor asked the patient (whether or not the patient was able to comprehend the situation is next) and she agreed. From the physician’s standpoint, he assumes that if the patient does get out of the hospital, she will die from the gangrene, and therefore by amputating the foot, (if she goes home) she could live a normal life. But I do think the fact that the nurse did not communicate (or the nurse did but the physician didn’t listen) presents a problem, because if Esther wasn’t able to think clearly, the doctor may not have done what the patient wanted to do, not to say that the family could make that decision either on the account of Ester is the only person that can decide whether or not she wants to die from an infection rather than her disease. Therefore I don’t think that the family has a claim on injustice because the doctor was providing the best care that he could for the patient, even though it was through a loophole.
ReplyDeleteScotty makes a good point about what is "extraordinary" in todays medicine. A decade ago the complex, expensive, high-tech treatments that are now commonplace and hardly "extraordinary." were seen as extraordinary. Feeding tubes were seen as an extraordinary means to extending life and now they are very common place in hospitals. I think that the use of the life staining medical equipment is more important then the actually equipment. I.E. a feeding tube for a patient who is recovering from a major surgery would not be seen as extraordinary, like a feeding tube for a terminal ill patient at the last stage of life. Another example would be a respirator/ventilator. It would be highly appropriate for a person fighting pneumonia but considered extraordinary for a person who is in a coma two weeks after a cardiac arrest.
ReplyDeleteI think in Esther's living will she may have said she didn't want to be helped in extraordinary means such as using chemotherapy, respirators, and resuscitation efforts in order to prolong her life, but she never really stated if she wanted surgery if something like gangrene was to happen and if she was not conscious enough to reply. I also agree with both Camille and Marion when they talk about different types of surgeries that use to be possibly life threatening or being a hard procedure isn’t anymore. I also believe that the doctor should have consulted with Esther’s family members before he made the final decision. I have the same opinion as Lindsay has when the family members may have known more about Esther than the doctor ever knew even if the doctor didn’t think they would. I feel like it would have been nice to have brought the family in this major decision. Overall, I feel like in this situation that it was very sudden and many emotions were put into play like Mrs. K’s fear of the doctor and of the family members not wanting to have the Doctor help anymore. I feel like this could be a problem with many other hospital situations and not just this one.
ReplyDeleteI have to agree with Christy and Scott because surgery doesn't fit into Esther's catergory of "extradordinary means" to prolong her life. She was specific when saying she didn't want chemotherapy, respirators, or resusitation efforts. So, technically the doctor did go by her living will. However, I think the nurse should have mentioned Esther's fear because then he could have seen that she is not fully herself, and then he could have discussed the decision with the family because they do know her best. Even though the family is upset, they knew that Esther was not herself, and they did not contact her power of attorney to make the decision for her. So, yes the family should have been involved in the decision with the surgery, but since the doctor was going off what he saw, (as Esther being in the right state of mind) they didn't have to be involved with the decision. Like Scott said, the doctor was just doing what was best for his patient.
ReplyDeletei believe it is very important for everybody to have a living will. With having this living will it should specify the things they want and do not want to happen. i think if at all possible the person preparing the will should discuss it with someone they trust - an attorney or family member, as well as their doctor. This case stresses the importance of this, but ultimately with a living will it should be the patient's decision, if capable of making choices.
ReplyDeleteFear of living or dying by the patient should never affect the ultimate decision of choicing treatment.
In this situation, the will is not specific enough to say whether she wanted surgery or not. Also, the gangrene has no relation to the cancer so i believe the doctor should go through with the surgery.
I have to agree with most of the post above. There is not a clear cut answer. Since Esther K wrote a living will I think it should be followed. Now that she is in a confused state, if the living will does not clarify for this kind of situation, I think the doctors should consult her power of attorney. I also believe like many others that amputating her leg would not be "extraordinary means." Yes eventually it could take over her whole body and she could die but it is not related to the pancreatic cancer. It is hard when the patient has a contradicting view when they are at the end of life. They may not be fully autonomous now but they still can feel emotions. I agree with many others about the fear factor. With Esther K approaching the end of her life, I believe she may have some fear and that can impact her decision. I think the doctors should maybe talk to Esther and her family together and see what they all think is the right thing to do. They may not all agree what is the right thing but hopefully that can make the best decision for the well-being of Esther.
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ReplyDeleteSo, Esther K has had a long history of diabetes and was diagnosed with pancreatic cancer. She then wrote her will refuting any kind of "extraordinary means" therapies that might be associated with her condition. It is not clear if she was competent at the time of writing this Will? After the diagnosis 'she was admitted in the hospital in a confused state....the Surgeon had no alternative but to help find the means of preventing the spread of the necrosis. again so many questions arises as to whether Esther K whispered to the nurse about her consent with regard to the surgery? A living Will to be considered morally decisive it must have been written while the owner is competent and also in the presence of witnesses and attorney for legal purposes. It's hard to determine how specific it should be because it is the owner's wish and desire for how things should be/go. There is a danger in assuming that a consent is valid merely because it coincides with what the physician wishes to do because based on the principle of autonomy, it is paramount to be respectful of the patient's will, and consent as well as the physician's and try to weigh the two. the surgeon's suggestion for amputating Esther K's leg would help prevent the spread of the gangrene. The family's judgment is based on the Will of their loved one and her wishes. They should be able to listen to the doctors suggestions and reasons behind his suggestions. I think since Esther was already in a confused state, the doctor should have talked to her family as well before proceeding with the procedures. Otherwise, to most extent I understand the family's fury since they were not part of the decision making and their loved one was already in a confused state...
ReplyDeleteI think the will should be specific enough to where you don't have questions, does surgery fall under extraordinary means? If these types of questions are popping up, then maybe they should describe to the patient what possibilities of treatment and life prolonging procedures are available, and then ask which falls under what category or what the patient would not want.
ReplyDeleteI think there is a danger in assuming about valid consent. Like in this case, the doctor wants to amputate the foot, due to the patient's consent, but the patient was in a confused state. The doctor needs to assess the patient to see if she is able to make that sort of decision, especially since her will states something like no extraordinary means.
The majority of the weight should be given to the family. Afterall, they know the patient best and what the patient would want. I also think the family has a right to be angry at the doctor. They were not asked about the decision when they should have been since they're loved one was in a confused state. I will say it's weird that the patient was worried the doctor would not take care of her, when she specified she didn't want extraordinary means, chemo, respirators/resuscitation, or aggressive therapies to prolong her life. Just what did she want the doctor to do then?
I think a living will should be very specific for it to be morally decisive. Doctors will do what is best for the patient unless the will or POA says otherwise. The doctor/surgeon should have taken into consideration the fact that Esther was confused and should have perhaps asked a family member or else view her surgery as extraordinary means. If Esther was scared that the doctor would no longer take care of her because of her decision against the surgery, why would she make a living will explaining not to do extraordinary measures? No patient should be scared that a doctor will not take care of them because of their decisions. Every patient has the right to say yes or no to a doctor. There is a danger in assuming that a consent is valid because it coincides with what the physician wants to do. If ester was really confused and the doctor went ahead and did the surgery, that could ruin esther for the rest of her life. He is going against her dignity in deciding that it is the right thing to do when she is not in the right state of mind. I do not think this could really happen. If there is a decrease in the level of consciousness, the surgeon will usually consent a family member if applicable. If Esther put her family in the will or picked a POA then the family should have a major input of the surgery. But, if Esther did not, then their opinion does not really matter, no matter how much they want it to.
ReplyDeleteI think a living will should be very specific to be morally decisive. When it comes to wills things become sketchy because the doctor wants to do want is best for the patient and different things can go wrong that requires the patient to be more specific on the will. Although the general public does not know everything that can or may happen to them. I think there is danger assuming a consent is valid. The patient could change her mind down the road and in this case surgery was not necessairly part of that will and the patient was confused when ahe agreed to the surgery. There should a great deal of weight given to the family because the patient was confused. If the patient was not confused and was competent then the family would not have a say either in the situation.
ReplyDeleteI think that the surgery did indeed go to "extraordinary means". What I wonder is if the nurse did indeed tell the doctor what Esther had whispered and if the doctor did know about the living will. If he did, then I believe he completely ignored her wishes. I do think that a living will needs to be specific and even put down examples. Esters specified "extraordinary means" which was good because it gave concrete examples of what she did not want.
ReplyDeleteEsther's family should have been called in on the situation because she was brought in while in a confused state. They should have been notified before the surgery happened.
I feel that in this specific case, the patient's living will described what she did not want and surgery was not one of those things. A living will should always be very specific, so that wishes can be fulfilled properly. The physician should have assessed the patient's level of confusion better, but also the nurse should have been a better patient advocate and went to the doctor after the patient whispered to her. The nurse had a responsibility at that point to tell the physician what happened and how she felt about the patient's level of confusion. When the family decided that the surgery would have been against what the patient's will said, the staff should have looked into the matter. Since the will does not say anything about not doing surgeries, then I don't feel the physician was doing anything wrong. When a patient signs a DNR form, the physician doesn't stop care, so why would they not perform a surgery because the patient doesn't want to resuscitation, chemo, or put on a respirator?
ReplyDeleteA living will must be as specific as possible. With diabetes and pancreatic cancer, there are many things that could go wrong, so the will needs to cover as many scenarios as possible. Esther K should have let the doctor or family know what she wanted to do if found in a confused state. If they had known this, there might not have been second guesses. There could be a danger in assuming that a consent is valid because it is what the physician wants to do. Patients may change their minds according to the situation or state they are in. The physician and patient may discuss what is best in many situations, but in Esther's case, it was not decided what she wished to do if she became confused. I think the doctor over stepped the boundaries in this situation and should have stayed with her wish of not wanting any "extraordinary means". Obviously the family would know the patient better than the doctor because of other decisions made in the patient's life. Living wills can be uncomfortable to talk about, but then your family would know your wishes if anythings sudden should arise.
ReplyDeletelike many other post, i believe that the doctor did follow the will because it never said anything about surgery. She was specific in what she did not want and surgery was not in that. The doctor did prevent the gangrene from spreading which may have saved her life. I agree with Julie in that a living will should be as specific as possibe in order for everyone to understand what it is that you exactly want. Therefore, i believe that the family should not get so upset about the situation that happened.
ReplyDeleteBecause the patient was not in a stable mental state, the surgeon is NOT ALLOWED to take this as the consent needed to do the surgery. The pt was not able to understand the risks and benefits of the surgery, the reason its needed, and the possible complications of the surgery. This is illegal. You are not allowed to consider a patient who is confused as a potential surgical candidate, unless they have an appointed POA who can weigh the risks and benefits for the patient.
ReplyDeleteRegardless of the patient whispering anything to the nurse, the legal documentation is what is important. If the MD deemed her to be competent enough to make the decision, he would have to obtain a psych consult to evaluate her decision making capabilities. In this case, it may be up to the family or POA because it is not likely that she will be able to legally give informed consent, which is required before surgery.
With that being said, the physician must treat any patient, even if they refuse surgery. They should be focused on symptom management at this point, if the family decides not to put her through surgery.
As said in many posts, I think that the family was wrong in saying that surgery is an extraordinary mean. Esther K was very specific in her definition of extraordinary means, surgery was not included in that. However, I think that if Mrs. K was confused when the doctor was explaining the situation of surgery to her, that he should have talked to the family or a lawyer representing her. If she was not in the correct state of mind to understand what was happening, someone should have been there to represent her.
ReplyDeleteIn this case of the Living Will, Ester's will was precicely outlined stating she did not want chemotherapy, respirators, or resuscitation effects. Surgery to remove her gangrene does not fall into any of those categories. Therefore the surgery was ok to perform. As for the consent, if Ester was confused then she could not consent to surgery. Therefore the family would have the right to be upset. In this case the Doctor should have explained to the family the situation and had a legal representative for the patient make the decision for the surgery. All-in-all though no harm acompanied the surgery and the surgery made the patient more comfortable in the long term.
ReplyDeleteIt is impossible for someone to cover every potential "what-if" scenario in a living will. By giving examples of what Esther considered "extraordinary measures" (i.e. chemotherapy, respirators), she implied what would be too invasive for her. Based on this evidence alone, I think that the doctor did the wrong thing by amputating Esther's foot. My interpretation of her living will is that she does not want any invasive treatments, even if they are trying to stop a disease that will take her life if it goes unchecked. Doing surgery likely prevented her from developing a secondary infection that would have killed her. But because she stated that she doesn't want invasive treatments, I think this overstepped the line. How is letting her die from gangrene and giving her pain medication to make her comfortable any different than letting her die of cancer (another disease which gradually destroys the body) and treating her in a similar way?
ReplyDeleteThe physician had an obligation to his patient to not only explain the pros and cons of a surgical procedure, but also to listen to her concerns and determine whether she was competent to make the call. Based on Esther's comments to the nurse, I do not think that she was in the state of mind necessary to make such a decision. Because of this, I feel the doctor should have contacted her family so they could discuss the situation with him. The family, then, has an obligation to carry out Esther's living will to the best of their abilities, and not to make choices to benefit themselves.
For a will to be morally decisive it should be extremely specific and detailed. In this case it should say she doesnt want any "extraordinary means" to prolong her life while losing to cancer. There is a danger assuming that the consent is valid because the pt is clearly in a confused state. If she doesnt want it then there could be legal issues that result but if he doesnt do it then she could suffer and the possible time she did have left could be taken from her and that could be seen as morally wrong. Very little weight should be given to the family's judgement because the family may have a motive that requires the death of Esther and Esthers life should be left in her hands if she is still alert and able to make somewhat legitmate decisions especially when it comes to stopping something that is separate from the cancer.
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