Essay About Current Pmd And Drug Addict

Dillemma In Clinical Medicine
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Dilemmas in Clinical Medicine, Sample Case Write-up
Dilemmas in Clinical Medicine
A 28 year old male was admitted to the hospital with
chief complaints of longstanding back pain, and left eye droop
for several weeks. He also had experienced some fecal
incontinence. He had been followed by this current PMD over the
previous 5 months. The PMD provided the past history of
Hodgkins Disease for the past 5 years. He was initially treated
with chemotherapy and went into remission. Approximately one
year ago he began to have back pain and paraparesis, and an
epidural mass was found. He began radiation therapy but
frequently missed appointments.
He had first presented to the PMD 5 months ago bringing
photocopies of all of his medical records. He indicated that he
had been seeing an oncologist who was treating him with
radiation. Admitting his non-compliance, he said he was tired of
all the cancer treatment and only wished to have symptomatic
treatment of his pain so he could “live out my time” peacefully
without pain. He said the oncologist would no longer treat him
if he did not go for the radiation. He had been receiving
Dilaudid from the oncologist and wished to continue it. The PMD
wrote a prescription for it and referred the patient to hospice.
Soon thereafter, the PMD was visited by a narcotics agent
from the NYS Health Department who indicated that this patient
had visited many physicians with the same story and had been
getting multiple prescriptions. The patient met with the agent
and the PMD in the doctors office and agreed to restrict
himself to this doctor in the future. A short time later, the
patients mother called the doctor and reported that the patient
has been addicted to drugs for many years (before the Hodgkins)
and simply used the illness to his advantage to obtain drugs.
Before the PMD could confront the patient with this, he was
admitted for the current hospitalization.
On examination, the patient was lethargic and febrile. He
had a dilated left pupil and nystagmus. His rectal tone was
diminished and when catheterized, had a large amount of urine,
indicating urinary retention. He rapidly became delirious and
then unresponsive. Neurologic W/U revealed obstructive
hydrocephalus. Neurosurgery placed a V-P shunt and he improved
modestly. When he worsened, the surgeons said the shunt was
obstructed, but they would revise it only if the patient
received aggressive anti-tumor treatment (RT and chemo).
The patients mother was consulted and she said she would
not want the aggressive treatment because “it wouldnt make a
difference; hell still be a drug addict.”
Discussion:
PROBLEM:
How do we make a substituted judgment for an incapacitated patient whose
prior statements were of questionable authenticity (because they were part
of an attempt to obtain drugs for abuse)?
ISSUE:
Standards for Decisions When Patients Lack Decision-Making Capacity
QUESTION:
Should we forgo shunt revision (with RT and chemo) and allow this patient
to die?
The Dilemma is whether to provide radiation/chemo to this
incapacitated