Mr. B.: Family Conflicts

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Case #1:

Mr. B.: Family Conflicts

Mr. B. is a 21-year-old African-American male who has been treated over the last year at your hospital for widely metastatic Burkitt’s lymphoma. Mr. B. had lived at home with his mother, but a few months ago against his mother’s wishes, he married his long time 17-year-old girlfriend who is the mother of his 2-year-old son. His mother does not get along with the patient’s wife. The couple have a small apartment and his wife has been trying to keep working nights as a nurses’ aide to support them. He’s applied for disability, but they currently have no consistent source of financial support except her part-time job.

 

Unfortunately, after his first course of chemotherapy, he became septic and nearly died in the ICU. His disease has continued to progress through second and third line treatment, and he has been hospitalized almost continuously for the last two months for dehydration and fevers, among other problems.

He has been evaluated for bone marrow transplant, but has steadfastly refused it because “I don’t want my family to lose everything because it’s probably not going to work at this point.” He has told you that he was pressured by his mother to have the evaluation: “It’s really hard to say ‘No’ to her. Mom told me she’d take the hospital to court, if they don’t do a full court press. She’s already contacted a lawyer. My wife can’t stand up to her, so I guess I’ll end up doing it even though I don’t want to.”

Questions:

1. What ethical principle(s) is/are at issue in this case?

2. Does this situation warrant an ethics consult from the hospital ethics committee? If so, who should initiate it?

3. What, if any, legal issues should be examined?

4. What patient/family issues should be addressed?

5. What advocacy role do you have as the oncology nurse taking care of this patient?

Sample Solution

Ethical Considerations and Advocacy for Mr. B.

Ethical Principles at Issue

Several ethical principles are at play in this complex case:

  1. Autonomy: Mr. B.’s right to self-determination and the freedom to make his own healthcare decisions, even if those decisions differ from the recommendations of the healthcare team or his family.
  2. Beneficence: The ethical obligation to do good and promote the well-being of the patient.
  3. Non-maleficence: The duty to avoid causing harm.
  4. Justice: The principle of fairness and equitable treatment.

Ethics Consultation

Given the complex ethical issues involved, an ethics consultation would be highly beneficial. The consultation can help clarify the patient’s decision-making capacity, explore potential compromises, and address the family dynamics that are impacting his care. The oncology nurse or the healthcare team can initiate the ethics consultation.

Legal Issues

  • Informed Consent: Ensuring that Mr. B. has the capacity to understand the risks and benefits of the proposed treatment and that his consent is voluntary and informed.
  • Advance Directives: If Mr. B. lacks decision-making capacity, exploring whether he has a living will or durable power of attorney.
  • Guardianship: If necessary, considering the legal process of appointing a guardian to make decisions on his behalf.

Patient and Family Issues

  • Family Dynamics: Addressing the family conflict and providing support to Mr. B. and his wife.
  • Emotional Support: Providing emotional support to Mr. B. and his family during this difficult time.
  • Financial Concerns: Discussing financial assistance options, such as Medicaid or other social programs.
  • End-of-Life Care: Having open and honest conversations about end-of-life care, including pain management and palliative care.

Advocacy Role of the Oncology Nurse

As an oncology nurse, you have a crucial role in advocating for Mr. B.’s best interests. This includes:

  1. Open Communication: Maintaining open and honest communication with Mr. B., addressing his concerns and fears.
  2. Empathy and Compassion: Showing empathy and compassion, and validating his feelings.
  3. Education: Providing clear and concise information about his condition, treatment options, and potential outcomes.
  4. Advocacy: Advocating for his autonomy and right to make informed decisions, even if those decisions differ from the recommendations of the healthcare team or his family.
  5. Collaboration with the Healthcare Team: Working with the healthcare team to develop a treatment plan that respects Mr. B.’s wishes and addresses his concerns.
  6. Involvement of Social Work: Collaborating with social work to address the family dynamics, financial concerns, and end-of-life care planning.

By addressing these issues and providing compassionate care, the healthcare team can support Mr. B. and his family during this challenging time.

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