13. CASE: Mind Over Matter?

Essie Marshall is well-known in the community for her many years of dedicated volunteer work and leadership. She is also well-known in the emergency department for her frequent visits. As one of the doctors describes her, “She’s a challenging patient, but not in the medical sense.”

Today Essie is back in the emergency department, saying she is terribly fatigued and has some “pretty bad stomach gas pain” at night. “I just can’t seem to get out of bed these days,” she tells the attending doctor. “You’ve got to give me something to boost my energy!” Dr. Gibson performs a careful physical examination, including a complete abdominal exam, the results of which are unremarkable. He suspects, based on further discussion, that her gas pains are due to gastroesophageal reflux disease (GERD) and tells her that he will prescribe an anti-reflux medication. He also spends some time explaining measures she can take to minimize her reflux symptoms. “But what about my fatigue?” she complains. “You haven’t given me anything for that and it’s worse than the stomach thing!”

Dr. Gibson isn’t sure what to do. With Essie’s history, any attempts at referring her for a psychiatric consult or to social work have been repeatedly refused. No previous tests or exams have revealed any direct cause for her fatigue. Many in the emergency department believe that Essie is lonely and not sleeping well since the death of her husband three years ago. Because they know her, they have a hard time trying to “get her out the door quickly,” even though they know Essie is taking up time and resources that could be used to reduce wait times.

In talking it over with the nurses on duty, the decision is made to give Essie a “prescription” for some vitamins and to give her a shot of vitamin B-12. This could help with her fatigue, but all are a little uncertain about how far to indulge Essie’s complaints. This will deal with her today, but what about tomorrow? Together the nurses and Dr. Gibson decide to call for an ethics consultation to talk about this case and the questions it raises.

[Case substantially modified from: Prescribing Placebos, Virtual Mentor 8(6): 377-380, June 2006 – see virtualmentor.ama-assn.org]

  • What underlying values should the staff involved in this case consider?
  • What ethics questions are raised in this case?
  • Is the prescribed treatment the same as giving her a placebo? Is this ok?
  • Is this the right way to handle “frequent flyers” such as Essie?

Some Values and Ethics Issues to Consider

  • Capacity
  • Patient-provider relationships
  • Resource allocation
  • Honesty, trust and truth-telling
  • Respect for professional integrity
  • Patient-centered care
  • Empathy

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