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Difficult Decisions in Cancer Care – Conducting an Ethics Case Analysis

The case outline refers to ‘low in mood’ and ‘eating little’. These are symptoms not diagnoses. Team members are likely to ask more about the statement ‘does not wish to live any longer’ and her refusal of professional contact particularly from her GP of many years. A specific diagnosis for these observations is required, reflecting either: a clear and fixed capacitous wish, transient reaction to diagnosis, potentially treatable depression, concurrent or associated illness e.g. dementia or hypothyroidism or hypercalcaemia or non-specific withdrawal as a consequence of advanced disseminated malignancy. As her previous low mood could have influenced her decision-making, this would require different responses from her professionals dependent on what proved to be the underlying ‘diagnosis’. It appears prudent to consider if a psychiatric problem could have impaired her prior capacity; her refusal of visits from her GP of many years could signify a change in behaviour sufficient to suggest there is a chance that more is going on in this case than a simple choice of not wanting to live any longer.

The ‘packets of soluble paracetamol around her’ may suggest a paracetamol overdose. If this is so, it is potentially fatal but can be reversible at presentation. The amount and timing of any overdose is crucial. Regardless, the default position is urgent referral to hospital for immediate medical attention as an overdose is potentially fatal with irreversible damage if not urgently treated. It is necessary to fully consider the relative merits of any healthcare intervention. The main choice to make is between:

some form of terminal care; that is supportive care alone, with a second-level decision of either remaining at home or admitting to the hospice. This course presumes that he/she will die over a number of days, with additional distressing symptoms – if he/she has taken an overdose – of liver failure, by which point the option to pursue antidotes will have passed should she change her mind. The less likely outcome would be a subfatal overdose resulting in a proportionate degree of liver failure from none to severe without any impact on survival; or

life-saving active care: send the patient to hospital to treat the overdose predicting that she would fully recover and return home (assuming that she could still get to hospital within the timeframe needed to reverse the overdose).

Patient Preferences

Does the patient have capacity? If so, what does he/she want? If not, has he/she expressed prior preferences? What is in his or her best interests?

The case outline states that Mrs Jackson is ‘incoherent’ suggesting she may lack capacity and not be in a position to express a preference. If Mrs Jackson is not competent to decide for herself then a decision may need to be made in her best interests as set out in the Mental Capacity Act (MCA) 2005 checklist.3

The team would ask if

there is an underlying cause to explain the confusion and clarify if this is a temporary or permanent loss of capacity. The default position may be to treat – if it is established that Mrs Jackson has taken an overdose – in case capacity could be established later. Why is she incoherent? As this would not be an expected result of a recent paracetamol overdose, she could be acutely unwell or intoxicated. Consequently, an overdose could easily have been accidental. Conversely, additional medication or alcohol could have been taken after a capacitous act of overdosing. The team might also ask if there


is a suicide note in addition to the living will requesting that she not be sent to hospital. Without it we cannot presume the overdose was deliberate despite her low mood and the fact that she had said she did not wish to live any longer.

Although competence could return, one view is that there is no option to defer hospital admission and treatment to wait until competence returns.

In terms of Mrs Jackson’s prior wishes, there was no prior refusal of treatment for the paracetamol overdose; however, this was potentially a deliberate attempt to end her life. This is supported by her refusal of hospital care and all medical interventions, visits from professionals and her statement that she did not to want to live any longer. A living will saying that she does not want hospital admission has no legal weight while she has capacity, yet it can still distract from discussions around decision-making while capacity is retained. Moreover, even if valid such an advance decision is unlikely to be applicable when capacity is lost. A blanket ‘no’ to hospital without parameters may not be specific enough to count. This was a predictable shortfall – a living will needs to clearly meet the MCA 2005 requirements and thus must be sufficiently fleshed out and widely shared (i.e. within advance decision-making/planning) to ensure it will be accepted at point of need.

The statement on the living will or advance directive ‘does not want hospital admission’ appears to add little, but cannot be ignored. Many people with advanced illness will be vocal in not wanting to go to hospital again when feeling relatively fit and well. However, when the time comes that they need to go to hospital, many will change their mind, particularly if a short stay with straightforward treatment appears to offer them a better quality and quantity of life. Additionally, as discussed, the legal weight of an unspecified blanket statement is extremely limited.

Ideally, the GP would have visited Mrs Jackson and conducted an assessment, however, this was not possible. In the community, the ‘lead clinician’ is the GP – the hospice nurse’s role is to contribute to the GP’s best interests decision-making – not to make a decision. Similarly, the hospice’s morning admissions meeting carries no weight in deciding best interests. The team decides if they are willing and able to provide the course of action confirmed as ‘best interests’ by the GP with or without adding to the GP’s decision-making process. Moreover, healthcare professionals never decide what to do to with patients, they merely estimate as best they can what the patient would want in the circumstances. Healthcare professionals clarify the clinical scenario and the treatment options. It can be argued that there is no ‘decision’ as there is no choice. The patient’s condition dictates the necessary treatments and the available resources clarify what the real world choices are at that time. The patient’s wishes determine the course of action (or inaction).

However, in this case Mrs Jackson does not appear to be able to participate in decision-making apart from her living will statement. There did not appear to be any legally designated decision-makers to involve. Her only relative, her son, is in Canada and the urgency of the situation meant it was not practicable to consult him. Indeed, it is not clear how well placed or informed a view of his mother’s wishes he could offer. The only other relevant views to take into account are those of her neighbour who telephoned the GP and said ‘something


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