Ethics and Care of the Terminally Ill
SUKHIT PHAOSA V ASDI, M.D.*, CHUMSAK PRUKSAPONG, M.D.***, HENRY WILDE, M.D.**, YUEN TANNIRANDORN, M.D.*
Affiliation : * Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkhon University, Bangkok 10330, ** Queen Savapha, Thai Red Cross Society, Bangkok 10330, *** Department of Surgery, Police Hospital, Bangkok 10330, Thailand.
CASE I
A 67 year old Thai-Chinese man with severe
Parkinson's dementia fell out of bed and broke his
hip. Bones were osteoporotic and the fracture was
fragmented and severe. Pain was moderate and
manageable by immobilization. The patient had
been unable to care for any of his personal needs
for at least two years. He did not recognize family
and had contractures of most major joints as well
as multiple bed sores. He was taken to a local pri-
vate hospital where he underwent total hip replace-
ment and, when he developed urinary retention, a
transurethral prostatectomy. His one month course
in hospital, mostly in the ICU, was complicated by
aspiration pneumonias, bilateral emphysema treated
with drainage tubes and a permanent tracheostomy.
His new hip also never remained in the socket. He
was maintained with a transoral gastric feeding tube
after placement of a gastrostomy failed. At the end
of these events, he was completely unaware of his
environment, responded only to strong painful sti-
muli and was kept alive for an additional 3 years at
home. This, only at great expense and involvement
of the whole family
DISCUSSION
Initially, there might have been hope for
restoration of the prefall state when he was aware of
his surroundings. Hospitalization and evaluation of
the extent of injuries after the fall was indicated.
However, this patient had not been ambulatory for
over two years, was debilitated and wasted and a
total hip replacement was not indicated. The family
may have accepted less invasive treatment if this
would have been explained to them. What was the
motivation of the doctors who performed the two
major surgical procedures? Cultural factors may
shed some light on this. This patient came from a
large and prosperous family with many friends. To
let him, the "Taipan" of the clan, expire without
benefit of ICU-care and attendance by prominent
physicians may not have been acceptable at first.
A sympathetic physician could have discussed
these issues with the family and found a humane
solution that would have satisfied all concerns and
given the patient more comfort at the end of life.
Such a solution could have been an order for
"symptomatic treatment only" (STO). It consists of
good nursing care, oral or intravenous fluids and
liberal analgesia.
Keywords :
