Angela Smith: A Case Study in Medical Futility

1. What is the essential content to be addressed in this conversation? (4 Different Themes) One of the most important aspects of this situation to address is how much the relative means to her family. These days having an older relative who shows pride and concern for their family can be one of its most precious assets. Being fully aware of this and emphasizing what she means to the family helps to establish a measure of empathy with family members.

The potentially tender issue of medical futility that Taylor (2006) raised should be carefully broached during the discussion. While there is always a chance that a patient may come back from a traumatic brain injury, in most cases as serious as Mrs. Smith's it is often quite likely that ongoing treatment will have no effect. Establishing a realistic expectation of care is what Quill, Arnold, and Back (2009) emphasized, and this has a twofold effect in that it both informs the family of the potentially fruitless medical efforts and also keeps their outlook on the situation more realistic in terms of expectations. Exploring other expectations aside from full recovery would be important in this scenario due to the likelihood of the family wishing to keep the patient alive. Such expectations would involve keeping the patient's condition stable and providing as much comfort as possible. Given the patient in question's religious and pro-life background, there is an ethical duty to consider the strong possibility that she would prefer this course of action. Returning the decision-making process at all times back towards securing the most desirable outcome for the patient is always important. Bringing the focus back on to this central idea while discussing any and all treatment options will keep the conversation both ethical and optimistic. Taylor (2006) suggested it is vital to provide all parties concerned with ample information regarding any current issues that might arise with the law, medicine or physician ethics. These things are important to consider even if opinions might differ on what the patient might have wanted their care to be, it is unusual for anyone to desire a course of action that would not result in the most comfortable course of treatment that may result in recovery.

2. Identify four to five objectives for your meeting. What would indicate, if achieved, an effective session?

Objective 1: Come to a consensus for treatment that all family members can agree upon. Objective 2: Convey a realistic set of expectations for any course of treatment considered. Objective 3: Explore all aspects (surgeries, therapies and/or medication) of any treatment plan that is seriously being considered. Objective 4: Establish a plan of action should the patient experience cardiac arrest. Objective 5: Arrive at a consensus for a treatment plan that the patient herself would have agreed with.

3. Identify the team you will assemble for the meeting and why you've chosen these disciples. Members of the team to be present at this meeting would be the patient's neurologist, family Doctor and a CNA that provides care on her ward.

The neurologist could provide the family with a clear picture of what has happened to Mrs. Smith's brain. The family Doctor can attest to what sorts of treatments Mrs. Smith has preferred to receive in the past, and might have an idea of how she would feel about this situation. The CNA can describe what sort of care Mrs. Smith would receive day in and day out. How she will be bathed, her bodily functions adhered to and other needs met can all be discussed with the CNA in question. This particular team could help to clarify any of the points concerning realistic results from medical care that Quill, Arnold, and Black (2009) mentioned in their study.

4. Script the conversation you will use to address the essential content you identified.

'We're all here today to discuss how to care for Mrs. Smith to ensure that she receives the most appropriate course of treatment possible. I know it is very difficult for everyone at this meeting to think about, but the truth is that your mother has suffered some serious trauma that mandates a high level of care.' 'Would your mother want everything to be done to keep her alive despite there being a strong chance that she might not come back?' 'Did your mother ever talk about whether or not she would be willing to have a feeding tube inserted to feed her if she could not feed herself?' 'In the event of cardiac arrest, do you believe that your mother would want to be resuscitated?' 'Do you think that your mother would be comfortable with having all of her needs met by other people?' Honestly, I found the thought of communicating with the family difficult. Any time I began to consider whether or not it was important to ask the family a question it crossed my mind just how 'matter of fact' it was. There is just so much emotion involved at the prospect of being in this position myself that discussing these things never quite seems like it can be genuine enough. While I certainly believe that I could be empathetic in a situation such as this, I know that words could never be good enough.

References

Quill, T. E., Arnold, R., & Back, A. L. (2009). Discussing treatment with patients who want "everything." (5th ed.). Annals of Internal Medicine, 151(5), 345-349.

Taylor, C. (1995). Medical futility and nursing. Journal of Nursing Scholarship, 27(4), 301-306.