Thinking back to what we learnt during Ethics, our duty is to our patient and therefore despite popular belief, we can over-ride family requests for the benefit of our patient if we do not think the family requests are in the patient's best interest. It sounds nice and simple, but I doubt it's easy to do due to an interplay of various factors at times.

Patient A and B are both Mr U's patients.

Patient A is an old woman, 90+ y.o. She presented with bowel obstruction. Is still clear in her mind and can speak well. She was an ex-nurse. She refused invasive procedures and had discussed this with her daughters. When Mr U did his ward round, he was talking mainly to her daughter at which point Patient A requested him to speak to her instead to her daughter regarding her treatment. She told him what she wanted and that she had discussed this with her daughters already. Mr U agreed and that her management would be a matter of watch and wait and give gastrogaffin and let nature run it's course and keep her comfortable meanwhile. After leaving the room, Mr U agreed that it was probably the best choice, rather than go in with surgery and then die in pain. As an onlooker I feel that Patient A is getting what is in her best interest, i.e. treatment as she wishes and maybe dying the way she would like.

Patient B is a woman of 80+ years who speaks only Mandarin and no English. She's presenting with vomiting two weeks after her partial gastrectomy for stomach cancer. Her son and daughter insists that she be treated with more surgery asap, or the daughter would take her mum back to China for treatment as soon as her mum is able to be moved. Mr U speaks no Mandarin and relies on the interpreter to communicate. He talks to the son and daughter as the mum shows no interest in proceedings. They talk above the bed, without involving the mum. The children do not explain to the mum what is to happen either, and treatment for her does not involve discussion withe mum. Once, on leaving the room, I saw Patient B shaking her head, unnoticed by anyone else, not Mr U, not her children. I doubt the children knows what Patient B actually wants with regards to her management. So does Mr U. Personally I'm under the impression she does not actually want all these treatment anymore. She had to be persuaded by fellow colleague who acted as interpretor once to accept the nasogastric tube and I was told it was reluctant acceptance on Patient B's part. Is it right to conceede to the children's requests? Is it worth taking time out to ask what Patient B actually is thinking, even if it means getting the kids out of the room? What if she wants no treatment? Is it alright to say no, my patient does not wish for further treatment and in light of her advanced gastric cancer and age, I shall not follow the requests put forwards by the children?

Talking it over with a friend, the friend came up jokingly with the conclusion that Asians are greedy for life (we all were Asians btw). I laughed and said nothing. I doubt if that is the case. I'm pretty sure that Patient B herself is ready to accept palliative care, but wether or not that is true no one will ever know because her children are not ready to accept it that their mum wouldn't last very long with invasive treatment and probably doesn't have very long to live anymore, with or without treatment and do not talk it over with her. No one will ever know because the mum doesn't attempt to put forward her views either. I think the baseline is that denial and ignorance will rob poor Patient B of a good end, unless, and I can't imagine this, the idea of a good end is to do everything even if it means pain right to the end.

Anyway, surgical OSCE this Tuesday, Path OSCE this Thurs. Whew! Study revise study revise! Aja!!!!