Matilda is a 68 YO female, whose husband died of advanced lung cancer 3 years ago. Her husband had a very difficult death with pain and shortness of breath.
Matilda presents with a left breast mass on exam, CT reveals a 5cm brain mass and metastatic lesions to C3/C4 vertebrae. Matilda states that she does not want treatment and want to be with her husband in heaven. You prescribe some steroids to palliatively help with the brain tumor.
Matilda has been less active since her husband's death and has lost 20 pounds. She refuses to talk to a breast cancer support group and insists she doesn't want treatment. You explain to her that her prognosis is 1-2 months without treatment; she [Matilda] understands and says she doesn't want to experience what her husband went through. She says she has had nightmares about his death and she cannot imagine facing those symptoms.
She [Matilda] read about palliative sedation and would like to go to sleep at home with palliative sedation while her sister cares for her until she dies from dehydration. She [Matilda] does not see why she should have to die in one or two months from advanced cancer when you can give her palliative sedation now. Matilda states that if you do not prove her with palliative sedation, she will figure out how to be euthanized in another country where it is legal
1)What are the ethical questions?
2)What are the clinically relevant facts? (Be sure to include both facts that you know already and facts that you need to gather.)
3)What are the values at stake for all relevant parties? (Values refer to such things as beneficence (doing good), non-maleficence (avoiding harm), respecting autonomy (self-determination), telling the truth, keeping confidentiality, keeping promises, respecting life, being fair, and so forth. Even if the party has not explicitly stated values, we can analyze what values are at stake for anyone in similar situations, i.e., respecting autonomy is always a value when you have a patient with capacity.) Be sure not only to name the values, but also state how each is applicable in the case. Also, be sure to clearly identify the conflict in values.
4)List options. What could you do?
5)What should you do? Choose the best option from the ethical point of view.
6) Justify your choice.
7)How could this ethical issue have been prevented / or how could we do better with these types of cases in the future? (Would any policies/guidelines/practices be useful in changing any problems with the system?)
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