In considering this scenario, you should particularly think about the following The macro issues these are

e refusal of treatment, competence, advance directives, substituted

decision-making, best interests, Hippocratic oath do no harm, treatment focus of medicine
What are the micro issues?
Identify the people who have responsibilities in this scenario
Is there any conflict between the macro and micro issues?
What might a plan to address this scenario include?

Is clear that our profession has abandoned the long tradition of paternalism for the new
practice of shared decision-making.
In addition many argue that the consequences of overriding autonomy are deleterious, and
that clinicians will reap their rewards if they are patient and allow the patient to make
decisions: in due time this approach would result in a better clinical outcome.
Although their skills are congruent with what is required for legal capacity tests, so an
assumption could be made that they are legitimately entitled to making decisions without
the interference of others, this does not consider at all the role that pathology and emotions
play in decision making.
An ethics of caring approach proposes that each one of us is embedded in relationships
and that because of this it is legitimate to raise an alternative concept of autonomy that
includes sensitivity to the interrelatedness with others. According to this view, family and
social networks are not only an important part of an individuals life, they are the very thing
that makes possible autonomous human existence in the first place.
Nevertheless after only 2 weeks of nutritional rehabilitation, a significant number had
already changed their minds and welcomed their hospitalization. The quality of the
relationship of the patients and parents with the treating professional is the basis of sound
decision-making. Patients have repeatedly described that having freedom of choice was
often less important than relationships and the attitudes of clinicians and those around
them. A majority of patients and their families say that their decisions are based on trust and
good relationships rather than on theoretical disquisitions about capacity. Most patients
initially treated against their will eventually do not seem to resent their experiences or
perceive them as coercion.
The patient is likely to say thank you at a later time.

MICRO

Current literature says issues such as disempowerment and the doctor-patient relationship
are inherently unequal as we (doctors) know more than them (patients). We have a body of
knowledge and people come to us sick and in a vulnerable position and mental health puts
an extra layer on this, even if the people with mental illness are well and functioning in
society a label of mental illness adds an extra layer of vulnerability and disempowerment.
Sharyn draws a comparison to how she worries her psychologist friend is thinking something
of her she doesnt know (shes a sane person so imagine for a person with mental health
disorder what this paranoia can do).

The other issue is mental health literacy and peoples understanding of health and
how they conceptualize (relates to public health). The general health literacy in the
public is not great, they have an understanding of the major disorders such as
mental illness (manic-depressive, schizophrenic etc) but people dont recognize
stress and anxiety as a mental illness, also depression is now becoming more highly
recognized.
The other big issue inevitably mental health calls into question is patients
consciousness or level of understanding. Sharyn expands on a famous case in the US
where a schizophrenic patient man had a gangrenous foot/toe and the team caring
for him wanted to operate to amputate cause the gangrene would spread. He said
no, I dont want you to, the surgical team said youre incompetent to consent
because you have schizophrenia and we are going to get a surrogate decision maker
to consent, the surrogate said he isnt incompetent. The case went to court and the
court ruled he wasnt incompetent (remember consent relates to the specific
operation of the amputation and the court said he was aware enough and
understood the risks and benefits of such a surgery so he could consent eg. he was
competent could make the decision). He later died of the gangrene. NOTE: Be
careful when you slap on a mental illness label that you dont fall into the trap of
thinking the patient is incompetent to make any decision afterwards (because as the
US case showed they may be capable).
Dealing with hope
This is very important and doctors seem to think that hope is binary,
you have hope or you destroy hope.
People have hope for life and if you go an say anything else you
destroy all hope and people wont have hope to live
It is clear in the literature that hope is not binary that there is an
analogue scale of hope and people dont just hope for life and lose it
if life is not possible but they can hope for other things, such as
getting to their daughters wedding, hope to see the first grand child
born, hope that they wont have to go into care at the end of their
life, that they will be able to die at home etc (time based hopes
that are realistic)
People understand the realities of situations once you spend time
with them discussing and being honest about prognosis however it
when doctors are not honest about prognosis because they fear that
they will destroy hope that patients and their relatives arent able to
hope for anything.
Setting realistic goals of care
In setting realistic goals of care can deal with some of the issues
mentioned above surrounding hope.
Often cure is not a realistic goal of care.
o If you had an end stage COPD patient and asked them their
goal and they said to get better need to inform patient not
going to get over this and its not going to get better than it
is now.
o May have to redirect to another focus e.g. asking about
activities they are doing at home example = walking 3km
to the pokies everyday, may not be achievable to walk to
the pokies but can think of another way to getting the
patient there.

May talk about home oxygen if the patients goal is to stay at

home and may have to start thinking about carers in order
to sustain this goal
Trust in the doctor patient relationship or doctor family relationship
This is important to maintain the relationship and this can be
achieved by being honest because people will sniff BS a mile away
(Sharyns words not mine hehe)
Futility
This is something that is contentious
This is variable depending on the patient e.g. what I consider futile
may be different to what someone else considers futile hence it is a
bit like best interest.
It is important to try and gain an understanding as to what the
patient and their relatives would consider futile
Sometimes not ever getting out of hospital may be someones
consideration of futile and any treatment that will keep the person
alive but in hospital may hence be futile in their perspective
however this may not be same view held by the relatives
In the above scenario recognise that there is a disconnection in the
patients and the relatives values, need to ensure that this
disconnection is discussed with everyone involved so that both
parties understand the difference
Liz Mallen in first year said that we know information that the lay
people may not know and their understanding is very different to
ours and time again we will be reminded of this (e.g. omg these
people dont understand that COPD is a chronic disease even though
its in the title, they dont understand that they are never going to get
over this), thus need to be able to plainly and clearly articulate this
information to them
The relationship of the patient to others, how does the patient exist, how
does the patient relate to others and what web of relationships is the
patient involved in and how is that going to affect end of life discussions and
decisions that are going to be made
Remember patients exist in families and exist in cultures and
relationships with religious people as well and need to take this into
consideration when discussing end of life.