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- What should we do when a man ask not to tell his mother that she has cervical cancer because she won’t be able to bear this bad news? There is no medical evidence to prove her inability.
- Should a patient in extreme high age (say 90 years) and with some chronic problem be admitted in ICU? We have very less numbers of ICU beds and plenty of patients.
- Should we resuscitate a dying patient? He will die anyway. Prolonging his life for some more makes him suffer with pain for some more time.
- How to proceed when a HIV positive women denies to tell her husband or call him in hospital?
- What to do if a patient demands a whole body CT scan or abdominal Video X-ray (USG) without any medical indication (need)?
- What should a senior doctor do when a staff of hospital comes demanding to see him immediately when a long queue of patients are waiting their turn since 5 hours or so?
- What should we do if a patient wants to go signing form of LAMA (Leaving Against Medical Advice) because of not having money to get treated? Etc. etc…
These questions have no appropriate answers. You are correct by both the way. You need to
act on best possible option for the patient and sometime for the population.
Skill of taking right and timely decision develops with experience.
There are things at PAHS which I simply find wonderful. One among them is exposing students to such ethical dilemmas by making student write a log on ethical cases so that they can handle those ethical issues appropriately. We have 8 weeks posting in each major department during junior clerkship of 3rd year. During these eight weeks, students have to write log proforma of eight patients out of which at least one should be an ethical case. We have to write the case and interpret it. The theory part of ethics is already taught in initial basic science years.
The cases student select are mostly interesting and
informative. We come up with several issues like- doctor scolding a patient
with words like “त डाक्टर कि म डाक्टर?” i.e. are
you doctor or I am? Then who should decide? Other issues like doing a Lumbar
Puncture (that is taking out of CSF fluid from the backbone for
investigation) without consent or permission. Doing surgery without
appropriately giving anesthesia. Missing some problems because of inadequately
examining etc. out of all the ethical cases one is to be presented by each
student individually, that is marked and added in examination.
Recently I too did my presentation. The associate professor
who was marking is a very inspiring faculty. He gives feedback very logically.
He always starts with positive feedback and in the end gives few suggestions in
constructive way. Five of us presented that day. After we presented the
concerned faculty admired us saying, “I am myself learning new things with each
presentations student make.” He added, “In the initial days, I used to search
where can I add some marks for student, but now I am searching where to cut off
some marks, but I don’t find it at any place.” His last sentence really made us
feel happy when he declared that he has given full marks. I need not say, marks
always counts in student life.
All the presentation was good. Let me tell about my case.
A baby from a village of Saptari, with no ANC visits and delivered at home started to have problem in sucking and breathing, he was taken to BPKIHS Dharan, where VSD (a defect in valve of heart) was diagnosed and referred to Gangalal Heart Centre, Kathmandu. The baby was receiving lasilactone (a drug) which was prescribed by Gangalal Heart Centre for VSD.
Patient party were in Kathmandu for operation at Gangalal Heart Centre. Baby was sent to our hospital for respiratory problem. He was admitted and treated adequately. During hospital stay, mother was advised to stop all the medications and nurses were giving medications as required. The baby got well by 10 days and was discharged after recovery. He was provided with the same drug given by Gangalal Heart Centre. Before leaving, patient party asked with nurses, “If they should continue medication given from Gangalal Heart Centre or not?”
Nurses advised to take them. As a
result, patient was taking double dose of that drug. Within 2 days, baby developed complication,
and was brought to emergency. During history taking baby getting double dose of a drug somehow went
unnoticed.
During history taking in night call, we, medical students found this and informed the duty doctor. She corrected the error then and there. They were lucky that medical students were assigned for them.
During discussion, I brought up series of things about
ethical issue.
This was medical negligence (willful negligence) by discharging doctor who didn’t properly talked to the patient during discharge. There was error of omission (i.e. not doing something you are supposed to do) by treating doctor who asked to stop the drug from other centers but didn’t explain when to resume it. The nurse suggesting to starting medications from Gangalal Heart Centre was also an error of commission (doing something you are not supposed to do). The conclusion was, ethical principles- beneficence (i.e. do good) and non-maleficience (i.e. do no harm) were breached. I was also not satisfied to the duty doctor whom we informed about the error. She corrected the mistake and counselled the patient. But didn’t give feedback or warning to the concerned hospital staffs.
There were also some social issues, associated with the case.
The poor family find hospital stay and canteen charge to be costly for four of them thus those days were being big burden for them. The 5 year old elder sister was missing her school, who came here with parents for the treatment of brother. In village, everything was being messed up. They have asked the neighbours to look after their cattle (cows, buffaloes and oxen). And It was rainy season then and they were worried saying “धान रोप्न पाइएन” that is they couldn’t crop their field, this might cause trouble to eat for the whole year.
This was all the case about. I hope it was interesting and you must have got somewhere more aware to your surroundings.
By reading this case, you might have thought that medical
personal are mostly negligent. And they don’t take the patient’s issue
seriously. Then that’s not true. The case I presented was one of the very rare
events. And if I had not found it, someone else would have. And even more, Patan
hospital, our teaching hospital is renowned for its ethical practice, giving
good information to patient, working for poor and underprivileged people. Let
me tell you, the social service of this hospital has its yearly budget of more
than a crore (10 million). The canteen charges are less than a half compared to
simple hotels outside the hospital. This public hospital is patient friendly in
all respect except that it is highly crowded thus rich people would hardly like
to come here. Even if they do, they come to private clinic of this hospital
which charges them comparatively high. And again the income of private clinic
and private wards are used in social service of the hospital for poor who can’t
pay.
Obviously, Its a proud to have a privilege to be associated with such a medical school and hospital, with high morals.
GREAT POST BRO................
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