Forgoing Medical Therapy: Post-Assessment


Forgoing Medical Therapy

  
 

Post-Assessment

Word document
  1. Question Set #1
  2. Question Set #2
  3. Answer Set #1
  4. Answer Set #2


Question Set #1

Mr. Delman was diagnosed with prostate cancer 3 years ago at the age of 74. He received radiation therapy and did well until about a year ago when he saw his doctor for back and leg pain. At that time it was discovered that his cancer had spread to his bones, bladder, and liver. Mr. Delman chose to forgo further curative therapy at that point and enrolled in a hospice program. After a few weeks of relative comfort, Mr. Delman has become increasingly unresponsive and uncommunicative and appears to be extremely uncomfortable. Most of the time he moans loudly and moves restlessly in bed.

Mr. Delman is the acknowledged patriarch of his family. He and his wife have attended an Orthodox Jewish temple since their marriage 52 years ago and have raised two sons and one daughter. Their three grown children are married and live nearby. All three children continue to attend the same synagogue as their parents but are more lenient in their religious observation.

The nurse who had been assigned to Mr. Delman recently left the agency to move to another state. You volunteered to pick up this case and are making your second home visit. At the first visit, you were concerned about Mr. Delman's level of pain but Mrs. Delman assured you that it was a transient change. Now, just four days later, you are alarmed to see that Mr. Delman appears to be in even greater pain. You also realize, after talking with Mrs. Delman, that the pain management regimen ordered by the physician is insufficient and that even this is being further reduced by the wife.

1. Considering Mr. Delman's religious and cultural background, what might be behind the apparent inattention to relieving Mr. Delman's suffering with pain medications?
 
a. There is no cultural or religious explanation for allowing a person to be in pain.
b. The family needs to be informed about the doctrine of double effect from the Catholic tradition that allows pain to be relieved even if it results in hastening death.
c. The family may be following the father's wishes by carefully insuring that his death is not hastened by the use of pain medications in accordance with orthodox Jewish teachings.
d.

The family appears to be hateful towards the father by allowing him to be in pain. Adult Protective Services should be notified and Mr. Delman should be removed from the home.

 

2. By refusing further curative therapy was Mr. Delman. . .?
 
a. Requesting assistance with suicide?
b. Requesting voluntary active euthanasia?
c. Requesting that curative therapy be withheld?
d.

Asking the healthcare providers to participate in an illegal act.

 



Question Set #2

Mrs. Freeman has end-stage cardiomyopathy and has just been discharged for the third time this year following hospitalization for shortness of breath, fluid overload, and cardiac arrhythmias. Following this discharge her primary physician made a referral for visiting nurse services even though she has only Medicaid coverage and the services will likely be challenged. Mrs. Freeman is assigned to your caseload as a home health nurse. On your first visit you discover that Mrs. Freeman's favorite food is Campbell's chicken noodle soup. You explain that this is not an option on her low salt diet, to which Mrs. Freeman replies, "Honey, that is the only thing I get to enjoy any more and you're not taking it away from me!" A few minutes later while you are measuring her ankles and listening to her lungs, she asks you if the salt in the soup really could kill her. Then she says, "I might need to have something like that handy if things continue like they are going."

1. Should Mrs. Freeman continue to receive home health services if she continues to eat high salt foods?
 
a. No. If patients refuse to be compliant with therapy, they should be discharged from care.
b. No. Why bother? There is nothing that can be done for her anyway due to her cardiac disease.
c. Yes. While consuming salt will make her disease more unstable, that does not mean that Mrs. Freeman should be abandoned.
d.

No. Mrs. Freeman is clearly suicidal and needs to be admitted to a mental healthcare facility since she is a clear danger to herself.

 

2. How should you respond to Mrs. Freeman's last comment respectfully? (Choose all that apply)
 
a. Call the crisis hot line and tell them that Mrs. Freeman is suicidal.
b. Ask what she means by "the way things are going"?
c. Tell her that your home health agency doesn't offer that kind of service and ask her to not bring it up again.
d.

Ask her if she is saying that she wants to hasten her death.

e. Call the state Medicaid office to report a non-compliant patient.

 



Answer Set #1

1. Answer: C.

Considering Mr. Delman's religious and cultural background, what might be behind the apparent inattention to relieving Mr. Delman's suffering with pain medications?

The family may be following the father's wishes by carefully insuring that his death is not hastened by the use of pain medications in accordance with orthodox Jewish teachings.

For some religions and cultures, pain at the time of dying has meaning including redemption, self-awareness, punishment, or enlightenment. In addition, while the majority of American culture accepts the doctrine of double effect, it is derived from Catholicism. This belief is not shared by all Orthodox Jewish persons. In fact, some rabbis suggest that death should be forestalled by the judicious use of noxious stimuli such as noise but does not need to include "rubbing salt into a wound." Another helpful way to think about this issue is to consider whether pain should always be relieved regardless of the patient or family's wishes? If yes, what about labor pain during childbirth? Are some types of pain "better" than others? This is a useful exercise for helping students consider other values around pain.

2. Answer: C.

By refusing further curative therapy was Mr. Delman. . . ?

Requesting that curative therapy be withheld?



Answer Set #2

1.

Answer: C.

Should Mrs. Freeman continue to receive home health services if she continues to eat high salt foods?

Yes: While consuming salt will make her disease more unstable, that does not mean that Mrs. Freeman should be abandoned.

2.

Answer:
 B & D.

How should you respond to Mrs. Freeman's last comment respectfully?

Ask what she means by "the way things are going?" And, ask her if she is saying that she wants to hasten her death.

�2001 D.J. Wilkie & TNEEL Investigators