Group 3B4 Chan Ying (1155048012)

Chow Pauline Jia-Ling (1155050330)

Kwan Chun Yin (1155047629)
Li Ka Ho (1155047443)
Case Summary

Mr Lau is a 89-year-old old age home resident for about 8 years after an episode of stroke
resulting in right hemiparesis. He was wheelchair bound since then. He was never married
and is only visited by his two sister regularly .

Two weeks ago, Mr Lau was admitted to the orthopaedics ward for fractured right hip after
he fell from his wheelchair. The orthopaedic consultant Dr Shan did not think he was a
surgical candidate for hip replacement because of his poor health status and the fact that he
was already wheelchair bound in his premorbid state. The next few days passed and Mr Lau
became feverish and coughed fiercely with purulent sputum. The diagnosis of hospital
acquired pneumonia was subsequently made. Intravenous antibiotics were given but he did
not get better and struggled hard to maintain oxygenation despite maximum amount of
oxygen was offered via face mask.

In view of Mr Lau’s deteriorating condition, the orthopaedic resident Dr Lo contacted his two
sisters and explained that if their brother was not connected to a breathing machine he
would die soon. The sisters agreed to intubation and mechanical ventilation. Mr Lau was put
on tube feeding as well.

Dr Hong is the orthopaedic intern who has been responsible for Mr Lau’s care for the past
weeks. He was distressed at repeating arterial blood taking from Mr Lau to monitor his blood
gases as Mr Lau had to endure significant pain from the procedure. Multiple bruises were
evident on Mr Lau’s arms. In his opinion, keeping Mr Lau alive on the ventilator was torturing
him. He felt that his senior Dr Lo did not explain clearly the risks and benefits of the
treatment plan to the family.

Mr Lau’s respiratory status improved and he was weaned off the ventilator after a week.

However, only a day later, Mr Lau developed difficulty in breathing again. Dr Lo seeked
advice from the consultant Dr Shan and she agreed with re-intubating Mr Lau. Dr Hong was
told to call the anaesthetist to perform the intubation. Dr Hong is very concerned that putting
Mr Lau on the ventilator again would be futile as he is not likely to make it and all this is
prolonging his suffering. Thus he feels uncertain about calling the anaesthetist.

Ethical dilemma

The main point of concern in this case is whether re-intubation is doing harm or good to Mr
Lau. The saying “To cure sometimes, To relieve often, To comfort always” is very true to the
medical profession. Patient involvement is critical to arranging the most appropriate
management. In this case, before arriving to the conclusion that mechanical ventilation is
futile, Mr Lau’s own idea and perception should be sought first. A 89-year-old stroke patient
is not necessarily mentally incompetent. After a definite diagnosis is made, the possible
steps of management could be outlined to Mr Lau if he wishes to know and is able to
understand. After weighing out the risks and benefits of intubation, we should hear what Mr
Lau thinks of the procedure and whether he is absolutely against this even if his life is
dependent on it. This also highlights the role of advanced directive throughout the course of
clinical decision-making.

Another thing to consider is the quality of life in the premorbid state. We cannot assume Mr
Lau is not enjoying life by the mere fact that he was wheelchair bound. In the case of a
Group 3B4 Chan Ying (1155048012)
Chow Pauline Jia-Ling (1155050330)
Kwan Chun Yin (1155047629)
Li Ka Ho (1155047443)
patient with good quality of life prior to the event, more aggressive approach in management
would be taken.

In this particular case, all doctors are working in the orthopaedics department but what they
were dealing with is chest infection. Input from medical colleagues such as geriatricians and
pulmonologists would be very valuable in deciding whether an intervention or treatment is
futile or not. Not only will they provide expert medical knowledge but they are also
independent from hierarchy issues.

Any records of advanced directives should also be looked into. They were drafted when the
patient is confirmed to be competent and usually it is a thoughtful decision. Patient’s
autonomy should be respected. Most important of all it carries legal liability.

GMC good medical practice highlights what it means to be a good doctor and it states:
“establish and maintain good partnerships with your patients and colleagues”. Some doctors,
especially junior doctors, may consider the culture of speaking up a rather disrespectful
behavior in the collegiate culture of medicine. This concern may be on a par with the
concern for patient safety. Poor relationship within the management team not only affects
the safety of the current patient, but compromises the safety of other patients in case
miscommunications are to persist. Thus, an ethical dilemma may arise from the issue of
teamwork and expressing opposing opinion about patient management.

Questions to consider

1. What constitutes futility of a treatment?

A futile medical treatment can be defined as a treatment that does not benefit the patient as
a whole, including physical, mental and social well-being. However, the current definition is
mainly based on the likelihood of patient to physically recover from as a result of the
treatment. As a result, some would advocate a discontinuation the use of any treatment if,
according to evidence-based medicine, the treatment failed to demonstrate a measurable
physical recovery.

A point to note is that, the definition of futile medical treatment does not take into
consideration of other stakeholders involved, whom may potentially “benefit” from the
treatments given to the patient.. (e.g. the psychological comfort and hope that the treatment
can give to patient’s family). This raise the question of whether the effectiveness of treatment
should be measured solely based on patient’s physical recovery. Or perhaps a summation of
“cost” and “benefits” of all parties involved would be a more accurate measurement of the
treatment efficacy.

The definition of a futile medical treatment carries great impact not only to the patients and
their family, but also to the society as a whole. The main argument against provision of futile
medical care is the huge cost and burden to the state and medical professionals without
much return to the economy. The philosophy behind this argument is the Utilitarian ideal of
efficacy in resource allocation - i.e. due to the scarcity of resources, we should always make
decision that maximizes the cost-benefit ratio. And hence we do not “waste” resources on
the “futile” treatments which cannot bring any observable benefits to the individuals and the
society. Again, this raise the question of whether the usefulness of treatment can only be
measured based on the cost and return, or is there another way of defining whether a
treatment is futile or not.

2. Which one is the role of doctors, treating patients or prolonging their lifespan?
Group 3B4 Chan Ying (1155048012)
Chow Pauline Jia-Ling (1155050330)
Kwan Chun Yin (1155047629)
Li Ka Ho (1155047443)

In the ideal situation when treating patients’ wellbeing and prolonging their lifespan align, it is
easy for medical practitioners to act without hesitancy. In reality, we often find these 2 goals
somehow contradictory to each other. As in this case, giving the patient ventilatory support
can prevent impending death from respiratory failure and possibly giving the patient better
physiological reserve to combat the underlying pneumonia. On the other hand, the cost of
extending this patient’s lifespan is subjecting him to extended suffering, giving false hope to
the patient and family, delaying palliative care, and utilising finite resources.

In the International Code of Medical Ethics adopted by the World Medical Association, a
physician has a clear duty to act in the patient’s best interest when providing medical care.
One can argue that extending patient’s lifespan is one but superficial aspect of ‘patient’s best
interest’, which is easily altered by patient’s perceived quality of life of the extended lifespan.
It thus leads to the importance of communication with the patient to discover what exactly is
the the best interest to this particular patient in this particular time point. Thereafter, the
physician should bear in mind the obligation to respect humans life and patient’s freedom to
accept or deny a treatment. Simply put, it is a physician’s role to help the patient and it is
also his/her job to find out what kind of help the patient need, be it curative or palliative
therapy. Ultimately, as stated in the Code, it is the physician’s foremost role to always
exercise his/her independent professional judgment and maintain the highest standards of
professional conduct.

3. How can consensus be reached in case conflicts arise within the hierarchy of
doctors?

If conflicts concerning patient management arise, a third party may be introduced to provide
an independent view. (detailed discussion above). Doctors should explore each others’
underlying reasons, align expectations and clarify any misconceptions or misunderstandings.
If disputes persist, a case conference with the patient and/or family members may offer a
more comprehensive review of the case and jointly explore alternatives of patient care.

If the dispute is concerned with ethical principles, doctors may consult the local clinical ethics
committee or seek legal advice.