End-of-life issues: Case 2

Paul A Glare and Bernadette Tobin
Med J Aust 2002; 176 (2): 80-82. || doi: 10.5694/j.1326-5377.2002.tb04292.x
Published online: 21 January 2002
Evaluate the patient's medical condition

Firstly, it is important to clarify the diagnosis and its natural history, the known extent of the disease, the treatment options, what treatment has and has not been given and the prognosis. We know some of this information but not all of it. Do we really know that the drowsiness is due to renal failure? Is there evidence of sepsis? Could Jenny be hypercalcaemic? Has she taken the wrong dose of morphine? And there are other questions to be answered. How rapidly is the disease progressing? Does Jenny have metastases elsewhere? Does she have a stent? How long is she likely to live? In a patient with cancer, the situation is rarely so urgent that there is not time to take a history and conduct a focused physical examination and some basic investigations (such as a full blood count and biochemical tests).

We do know that Jenny has rapidly advancing cervical cancer and that there are no more antitumour treatment options available. Let us assume some further facts: she has a pelvic mass that is causing obstructive uropathy, a ureteric stent that is now blocked, a urinary tract infection and sepsis. Let us also assume that she has a serum creatinine level of 800 µmol/L and a potassium level of 6 mmol/L. You know that without treatment Jenny may have only a few days to live. To sustain her life beyond that, she will need admission to hospital, rehydration, intravenous antibiotics, an urgent stent change and possibly haemodialysis. Even with all these interventions, Jenny's prognosis is still measurable only in weeks.

Identify the key ethical issues

The decision that now has to be made is whether to admit Jenny to hospital for life-sustaining treatment. At this point, you need to recall four key aspects of medicine's own ethic: life-sustaining treatment may legitimately be forgone if it is


Implement the decision

At this point you have to decide whether you are prepared to consider offering life-sustaining treatment or not, and, if so, exactly what modalities this will involve (eg, hospital admission, antibiotics, dialysis, surgery, admission to an intensive care unit, cardiopulmonary resuscitation). Central to the art of medicine is the clinician's ability to choose what treatment options to offer. In Jenny's case, an urgent decision is needed, and consensus within the family, and between the family and the doctor, may not be achievable. In this situation, you may need to make a unilateral decision in the short term (based on the information available) about which treatment is in her best interests and start administering it, while at the same time sorting out who is going to be her representative in the longer term. If Jenny had no family members present when you made the house call, and it is unclear whether life-sustaining treatment should be withheld, then you should err on the side of sustaining her life until the appropriate goal of care can be clarified.

In all this, it is important to document in the medical record the decisions made, including the treatments and care that will be offered if life-sustaining treatment is to be withheld. In implementing the decisions made (including symptom control if life-sustaining treatment is being withheld), the use of a time trial of one treatment can be helpful in assisting a family to reach consensus. In consultation with Jenny's representative, you should be ready to change the decisions you have made at any time in accordance with significant changes in Jenny's condition, provided the new treatment choice continues to serve her overall welfare. You should also be prepared to respond to challenges to these decisions, as disagreements may arise about the appropriateness of your treatment decisions or about Jenny's capacity to indicate her own wishes. Indeed, Jenny herself may have moments of lucidity that offer you opportunities to elicit her present wishes.

  • Paul A Glare1
  • Bernadette Tobin2

  • 1 Department of Palliative Care, Royal Prince Alfred Hospital, Camperdown, NSW.
  • 2 Plunkett Centre for Ethics in Health Care, St Vincent's Hospital, Darlinghurst, NSW.



Thanks to Professor Norelle Lickiss and Dr Gerald Gleeson for helpful comments on an earlier draft.

  • 1. Chye RWM, Lickiss JN. Palliative care in bilateral malignant ureteric obstruction. Ann Acad Med Singapore 1994; 23: 197-203.
  • 2. Field MJ, Cassels CK, editors. Approaching death: improving care at the end of life. Washington, DC: National Academy Press, 1997.
  • 3. Fisher A. The principles of distributive justice considered with reference to the allocation of healthcare [DPhil thesis]. Oxford University, 1994.
  • 4. Randall F, Downie RS. Palliative care ethics: a good companion. Oxford: Oxford University Press, 1996: 64-65.
  • 5. Hastings Center. Guidelines on the termination of life-sustaining treatment and the care of the dying. Bloomington: Indiana University Press, 1987: 8.


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