Case Study 32 : OFFERING HOPE
Challenges
A 22 year-old male was admitted due to extensive chemical burn injuries involving the face, torso and extremities inflicted by his sister. Initial findings were severe anterior ocular ischemia with vision of counting fingers at one foot, both eyes. His condition deteriorated despite efforts made on both eyes, from corneo-scleral transplantation, to skin grafting on the upper and lower eyelids. Vision remained at light perception. The patient’s family insists that more tests be done, even as the doctors explain that the patient will probably not improve.
Question
Aside from the prognosis, what other considerations should doctors explain to the patient and his family?
Solutions
Health care workers deal not only with diseases and organs, but with persons. As a true profession (in the original sense of the word), medicine aims not simply to produce goods and services, but above all to help persons attain their goals in life, focusing on (but not being limited to) restoring health to allow persons to pursue their other legitimate concerns.
In the case presented the relatives propose undertaking probably futile measures. The doctor should explain how such options will not bring about any good, and will most likely waste of time, efforts and resources.
There remains the task of helping the family accept reality, however difficult it may seem, but at the same time, of offering them hope. For this, a certain personal touch becomes necessary, including a sincere showing of concern. Care cannot be limited to a mere technical activity of fixing body parts.
Doctors should avoid giving the impression of abandoning the patient and the family. In the case presented, the family might be suffering from dysfunction, since the sister inflicted the injuries. A referral to a counselor might be in order. Work opportunities for the disabled patient might also be explored, given his whole life ahead of him.
The ultimate way to lessen this risk involves the doctor ensuring free and informed consent: that the patient receives the necessary medical information, understands the information given, and exercises freedom in making decisions. Such orientation covers complications that may likely or unlikely arise, along with added inconveniences these could suppose for the patient (discomfort, costs, care, etc.).
At least two basic approaches exist in applying this principle of free and informed consent. The first is to remain extremely legalistic and explain details meticulously to the patient, documenting and seeking countersignatures for all explanations done. This approach can prove too tedious; besides, potential lawsuits could still arise, as some aspects of care might eventually be overlooked.
The second approach aims for an optimal interpersonal relationship between the health care team on the one hand, and the patient and family on the other. Strictly speaking, this goes beyond legalities; but in actual practice, this helps keep trouble away. With trust, the patient will more easily understand the possibility of complications even with the best of surgeons. Brought to the extreme, in the unfortunate event of inadvertence or error, the patient will easily excuse the doctor who strives to provide the best possible care.
