Ms. D.: Patient & Interdisciplinary Team Disagree on Treatment

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As a nurse working in an inner city medical center hospital, you take care of many underserved patients. On rounds with the gynecology oncology team, you meet Ms. D., a 33-year-old white unmarried woman with Stage IIIC ovarian cancer. Ms. D. has refused all offers of chemotherapy treatment for ovarian cancer that has now spread throughout her abdomen and inguinal nodes. She has malignant ascites and a bowel obstruction. Her condition has worsened to the point that she has to have daily paracenteses and the team has told her that they may have to operate to partially alleviate the obstruction.

She tells you she has schizophrenia and she hasn’t taken her psychotropic medications in a while because “they’re poison.” She tells you, “I may be crazy, but I’m not stupid. That treatment is going to kill me. I don’t want it.” The treatment team tells her that treatment is her only chance of curing her cancer, and they will contact her family against her wishes to make sure she gets appropriate treatment.

Assignment Questions:

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

2. Should an ethics consultation be requested?

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

4. Do you think Ms. D. is capable of being her own decision-maker? If not, what resources does your hospital have to assist in appointing a DPOA (Durable Power of Attorney) or guardian (social services, patient advocates, relationship with state Ombudsman)?

Sample Solution

Ethical Principles at Issue

Several ethical principles are at play in this complex case:

  1. Autonomy: The patient’s right to self-determination and the freedom to make her own healthcare decisions.
  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. An ethics committee can provide guidance and support in balancing the patient’s autonomy with the healthcare team’s duty to provide life-saving treatment.

Advocacy Roles of the Oncology Nurse

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

  1. Open Communication: Maintain open and honest communication with Ms. D., addressing her concerns and fears.
  2. Empathy and Compassion: Show empathy and compassion, and validate her feelings.
  3. Education: Provide clear and concise information about her condition, treatment options, and potential outcomes.
  4. Advocacy: Advocate for her autonomy and right to make informed decisions, even if those decisions differ from the recommendations of the healthcare team.
  5. Collaboration with the Healthcare Team: Work with the healthcare team to develop a treatment plan that respects Ms. D.’s wishes and addresses her concerns.
  6. Involvement of Mental Health Professionals: Collaborate with mental health professionals to assess Ms. D.’s mental capacity and to provide appropriate support.

Decision-Making Capacity

Determining Ms. D.’s capacity to make decisions can be challenging, especially given her mental health condition. Factors to consider include:

  • Understanding the Information: Can she understand the diagnosis, treatment options, and potential risks and benefits?
  • Appreciation of the Situation: Does she appreciate the seriousness of her condition and the potential consequences of her decision?
  • Reasoning: Can she reason logically about the information and weigh the pros and cons of different options?
  • Expressing a Choice: Can she communicate her choices clearly and consistently?

If it is determined that Ms. D. lacks capacity, the hospital’s social work department can assist in identifying a suitable surrogate decision-maker. This may involve appointing a durable power of attorney or a guardian.

It’s important to balance respecting Ms. D.’s autonomy with the ethical obligation to provide life-saving treatment. Open and honest communication, empathy, and a collaborative approach can help navigate this complex situation

 

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