20. CASE: To Treat or Not to Treat

Stan Miller, a retired widower, sustains severe burns covering 80% of his body surface in a house fire secondary to a propane gas leak. He is initially assessed in the ED of the local hospital where he is sedated and intubated without any pre-resuscitation discussion about the seriousness of his thermal injuries and his care preferences. He is transferred by air ambulance to the ED of the provincial tertiary care centre where he is assessed by an on-call, senior plastic surgery resident. The brief transfer documentation indicates that Mr. Miller has a variety of pre-morbid health conditions including type II diabetes, essential hypertension, coronary artery disease and moderate COPD. He is admitted to the Burn Unit from the ED.

Mr. Miller has three adult children, two of whom arrive on the scene shortly after their father’s admission to the Burn Unit. The children, David and Sarah, describe their father as a “go-getter” who approaches his retired life with enthusiasm despite his chronic health problems. They mention that he has been living with a partner, Cathy, who was away on a visit to Ontario to see her family when the fire occurred.

Mr. Miller’s three children had an informal discussion with their father a couple of years ago at Christmas time about what he would wish to have done if he ended up in an ICU Unit and could not make treatment decisions on his own. Mr. Miller essentially told them that his care preference would be to fight to stay alive.

A family meeting held on the Burn Unit is held in order to decide the course of treatment. It is attended by Sarah, David, the attending plastic surgeon on rotation, two residents and a nurse who provides direct care to Mr. Miller.

  • What issues would be important to discuss during this meeting?

Now Consider:

What if the above scenario is the same except that Sarah’s 17 -year old son Mike (Mr. Miller’s grandson) was staying over for the weekend when the fire happened and he too sustains severe burns- in his case, covering 90% of his body. He arrives with his grandfather by air ambulance after being sedated and intubated in the local hospital ED. In discussion with members of the health care team, Sarah comments that her son recently received an athletic scholarship to attend Acadia University next fall. She reports that he loves the outdoors and has always been in excellent health. The same plastic surgeon and residents and a nurse who directly attends Mike participate in a family meeting with Sarah and her husband in order to decide the course of treatment.

  • What issues would be important to discuss during this meeting?
  • Does the age and relative health of the patient in this scenario change the issues at hand compared to the first scenario?

Some Values and Ethics Issues to Consider

  • Substitute decision-making
  • Advance care planning
  • Pediatric ethics
  • Resource allocation
  • Patient-family relationships
  • Quality of life

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