Monica, a forty-nine-year-old divorced mother of two children in their early twenties, was admitted to the hospital for acute respiratory insufficiency on a Friday evening. She is a heavy smoker and had experienced dyspnea for several weeks previously, but had not sought medical advice. Chest x-ray revealed several abnormalities and a bronchoscopy was scheduled for Monday morning.
On Saturday evening Monica's difficulty breathing worsened and during a heavy cough of sudden onset she became cyanotic and nearly lost consciousness. The physician on call performed an emergency intubation and transferred her to the intensive care unit, where she was heavily sedated. On Sunday, a bronchoscopy was performed, revealing a large, tumor-like mass in her trachea. Biopsies were taken from the mass, and from a palpable lymph node. On Monday the pathologist confirmed the presence of tumor cells and a diagnosis was made of a poorly differentiated squamous cell carcinoma of the lungs metastatic to the lymph node.
The multidisciplinary treatment team agreed that the tumor is inoperable (by either surgery or laser) and chemotherapy and radiation therapy are of unproven benefit. Monica cannot be extubated because the tumor will immediately obstruct her airway, and tracheostomy would be very risky--and probably not feasible--given the size of the tumor. Implanting a stent would also be difficult with so advanced a tumor. The team believes Monica's life expectancy is no more than three months.
The team discussed the following alternatives for Monica's care: they could withdraw life-sustaining measures; continue mechanical ventilation and heavy sedation but not treat any complications, such as infection, that arise; persuade (or coerce) the surgeon to implant a stent without consulting Monica; or wake Monica so that the team could discuss the diagnosis and prognosis with her and ascertain her preferences among the treatment alternatives.
The team is concerned that Monica will not really be able to make an informed, autonomous decision if they wake her. They worry that being intubated without sedation will impose further suffering for Monica, only to allow them to impart a grim prognosis. Should they wake her, or should they make treatment decisions on her behalf?
by. Bernice S. Elger
When Monica lost consciousness she knew only that she was in the hospital to be treated for an acute lung problem. We do not know why she did not seek treatment earlier--did she perhaps fear lung cancer? Even if she did, she cannot be supposed to be aware of the severity of her illness and of the small amount of time left to her to live.
The principle of autonomy, so central to...
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