to hospital
Harry is admitted to hospital
View Harry’s story below.
pathological fracture of his lumbar spine.
now been diagnosed as advanced metastatic renal cell carcinoma.
nurse. She sees him intermittently.
spinal cord injury.
and coronary artery disease.
surgery to stabilise his fracture, but he is a high-risk surgical candidate.
nursing staff as to whether he should have the surgery or not.
day of surgery,
Harry is now ambivalent.
pathological fracture of his lumbar spine.
now been diagnosed as advanced metastatic renal cell carcinoma.
nurse. She sees him intermittently.
spinal cord injury.
and coronary artery disease.
surgery to stabilise his fracture, but he is a high-risk surgical candidate.
nursing staff as to whether he should have the surgery or not.
day of surgery,
Harry is now ambivalent.
how they should proceed in light of Harry’s indecision.
Harry is a 67 year old man admitted under the neurosurgical team with a pathological fracture of his lumbar spine. The fracture was found to be secondary to a bone metastasis from what has now been diagnosed as advanced metastatic renal cell carcinoma.
He is a jovial, engaging man, now retired and a widower of 5 years. He lives alone, manages independently, and enjoys gardening. He has one adult daughter who lives 3 hours away and works as an enrolled nurse. She sees him intermittently.
Harry’s bone cancer-related fracture puts him at risk of a catastrophic spinal cord injury. He has significant comorbidities, including severe ischaemic cardiomyopathy and coronary artery disease. The neurosurgical doctors have looked at his scans and are prepared to offer surgery to stabilise his fracture, but he is a high-risk surgical candidate.
Since admission, he has had various conversations with members of the nursing staff as to whether he should have the surgery or not. He agrees to the surgery. However during the morning ward round on the day of surgery, you observe the resident asking Harry to sign the consent form. Harry is now ambivalent.
Audio “There could be a serious risk to your spinal cord if you don’t have this surgery. You are booked in this afternoon”.
Audio “Look can we just leave it for now; my back hurts, and I’m finding talking about all this too difficult.”
Which of the following best represents your thoughts about how to proceed?
Harry has metastatic cancer so he is now a palliative patient. He should never have been offered surgery.
A palliative approach does not necessarily mean that surgery should not be offered. Each intervention is considered carefully in the context of the specific person, their symptoms, and their quality of life related goals and values – Explore another option
It is really up to the clinical team to make the decision.
It is up to the clinical team to come to some opinion about what treatments could and should be offered, but it is up to Harry to decide what treatment he will accept. Ideally, this should be a ‘shared decision-making’ process involving Harry– Explore another option.
Shared decision-making
Shared decision-making is a process where the clinician and patient (and sometimes their family, partner or carer) make health decisions together. This is central to determining what is in an individual person’s best interests in relation to healthcare.
Delay the surgery and gather more information
This would be reasonable given the circumstances. Determining what is ‘best’ for Harry is not easy, and Harry is having difficulty with the decision. People may defensibly arrive at different assessments of what may be in Harry’s ‘best interests’. Where there is a diversity of views between different stakeholders, we look for consensus through ‘shared decision-making’. We are obliged to give Harry the best possible chance of understanding his options and making a considered decision.
Best Interests
Best interests is an important but contested term. To act in someone’s best interests is to act so as to benefit them. This involves evaluating and balancing all the elements important and necessary to make a decision in a specific situation for a specific individual. This is a fundamentally ethical process, and core to clinical practice.
Shared decision-making
Shared decision-making is a process where the clinician and patient (and sometimes their family, partner or carer) make health decisions together. This is central to determining what is in an individual person’s best interests in relation to healthcare.
Harry was agreeable to the surgery up until this morning. The pain is clearly affecting his judgement, so we should go ahead with the surgery as planned.
The surgery cannot go ahead without consent. If Harry refuses the surgery, we would have to consider his refusal in the context of his decision-making capacity, his preferences, and the risks of surgery, as well as the risks of not proceeding with surgery – Explore another option
Harry has metastatic cancer so he is now a palliative patient. He should never have been offered surgery.
It’s really up to the clinical team to make the decision.
Delay the surgery and gather more information
Harry was agreeable to the surgery up until this morning. The pain is clearly affecting his judgement, so we should go ahead with the surgery as planned.