- Derek White a 75-year old man is now 6 weeks post a left total anterior circulation infarct (dense right arm and leg weakness with aphasia) with no recovery of the initial severe deficit. He is NG fed and cannot talk or walk. He is doubly incontinent. The chances of him making a recovery to independence are poor.
- He has had 3 aspiration pneumonias and develops a 4th episode. The on call team have started antibiotics.
- You feel that further episodes of life prolonging antibiotics may not be in his best interests as the chances of recovery are poor.
- His family have already been informed.
- His wife had previously indicated that she felt that he’d ‘had enough’ and should be allowed to die peacefully.
- His son, who had up until now been content with the care his father had been receiving, and seemed to be aware that his father might not survive, now wants everything possible done and thinks that ‘if he just had a bit longer with feeding and one more course of antibiotics he will start to recover and get back home’.
The patient in this case is fictional but based on real cases. The following video contains still images and audio. If you are having issues with opening the interactive video, please follow one of the alternative video links below.
Video notes
3:01 Here the doctor is hinting at the futility of antibiotic courses (but note that it’s best not to use the term ‘futile’ when discussing treatments with families).
3:12 Note that this change in emotion from being confrontational to being tearful may indicate a ‘transition’ from hope to being more realistic.
3:20 The Doctor is frustrated as the son had been involved in previous discussions and had appeared to agree with the management. Note that it’s important not to ‘side’ with a particular family member (in this case it would be easy to ‘side’ with the wife but it’s crucial to continue to engage with and support the son too).
3:43 The doctor feels that the son is not ready to accept stopping the current course of antibiotics, and in any case you feel that the current course is probably not going to change the outcome as he is so unwell, and you feel that the treatment is not too burdensome. This seems to be a reasonable compromise. But you know that you will need to talk to the son again soon as his expectations seem unrealistic given the situation.
4:16 It may be possible to reach this agreement at the next meeting. The Nurse takes a mental note to try to catch the son later, and to let the rest of the team know that the son is finding this situation difficult and still wants his father to survive and go home. She wonders if there is any reason for his reluctance to accept that his father is so unwell.
After the meeting, Mr White’s wife approaches the doctor in the corridor.
4:58 Sometimes individual family members ‘catch’ staff in corridors or at the bedside. These informal or unplanned interactions can be helpful as family members may be more willing to express views or provide important information which can then be shared with the rest of the team. It is not always necessary to find a quiet room to have these spontaneous or unplanned conversations-it depends on how quiet the ward is, whether you can find a quiet ‘corner’, whether you sense that the family need a lot of time etc.
Note that these unplanned interactions can also identify conflict within families that might not be obvious in a larger family meeting. Or as in this case, identify reasons for conflict (e.g. guilt). Family members may want to say something that they don’t want their siblings to hear.
- This audio clip demonstrates the dilemma about repeated courses of antibiotics and clinically assisted nutrition.
- After the meeting with the son and wife, the wife ‘catches’ the doctor in the corridor and tries to explain some background about the son’s views.
- It is important that all members of the family should be involved, if possible, in the important discussions about goals of care, even if the team find it easier to communicate with some members of the families than others.
Page last reviewed: 16 Jan 2023
