Professionalism and ethics

Case studies

Doctor’s duty of care and patient autonomy

Case 1
You are term 1 registrar working part-time in general practice. Your last patient for the day is Harry, an 86 year old retired labourer who has advised reception that he just needs a script. As you call him you observe that he is visibly breathless even before walking the short distance from the waiting room to your room. This is the first time you have seen him and a review of his medical record reveals that he is overdue for this puffers. He has had two admissions for COPD exacerbations requiring ventilatory support in the past 6 months. He also lives alone and has refused services.

After history and examination you confidently diagnose a severe acute exacerbation of COPD and recommend that he be transferred to the emergency department for further treatment. Harry refuses to go to hospital and firmly states he just wants his puffers.

Case 1 - How would you manage this situation? What ethical principles did you consider?



Case 2
You are term 3 registrar working in a small rural town. Frank is a 90 year old with metastatic prostate cancer. For several months you have been doing fortnightly home visits to manage his palliative care. You have also had to make occasional additional home visits out of hours when he has had symptoms that have been difficult to control. You have now achieved good symptom control even whilst his general condition has declined. Frank has been very appreciative of your care and always insists that you stay long enough for a cup of tea during which you chat about issues unrelated to his health. He has also previously stated that you remind him of one of his children.

During your routine home visit today he tells you he has been doing some thinking and has decided that he has nothing more to achieve in life. He goes on to say, “I have had enough. I know I’m not depressed, but I am ready to die and I want to die with dignity. What can you do to help me?”

Case 2 - How would you manage this situation? What ethical principles did you consider?