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four box paradigm case study

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CASE 1
A 50 years old male patient was brought to ER by his family in unconscious conditions. Family
mentioned initially patient complained of having headache since morning, accompanied with
nausea and vomiting, then followed with gradual decreased of consciousness since 3 hours ago.
Initial examination found poor GCS score (E1V1M2), while CT scan confirmed Intra Cranial
Hemorrhage (ICH) in posterior fossa, with clot size of approximately 3 cm. Patient had history
of chronic hypertension, and without history of head trauma. Doctor was unsure of whether to
perform surgical evacuation of clot, because there was risk for death during surgery, otherwise
survival usually yields severe permanent neurological deficit, such as persistent vegetative state.
However, family insisted that all possible intervention must be performed at all costs, including
surgery, even if it might result worse outcome such as death or permanent major neurological
deficit. What should doctor do/ suggest to patient and family in this case?
Clinical Ethics Worksheet
1. Identify the facts
Medical Indications
Based on the medical indications, the patient has
suffered an intra cranial hemorrhage (ICH) in the
posterior fossa with a clot size of approximately
3 cm. The patient's Glasgow Coma Scale (GCS)
score is poor (E1V1M2), indicating severe
neurological impairment. The doctor needs to
consider the risks and potential benefits of
surgical evacuation of the clot. Surgery carries
the risk of death, but not performing surgery
could result in severe permanent neurological
deficits. The medical indication suggests that
surgery is a potential option to consider.
Patient Preferences
The patient is currently unconscious and unable
to express their preferences. Therefore, the doctor
needs to consider the values and wishes of the
family as surrogate decision-makers. The family
insists on pursuing all possible interventions,
including surgery, regardless of the potential
risks and outcomes. The doctor should have a
conversation with the family to understand the
basis for their request and explore their
understanding of the risks involved.
Quality of Life
The potential impact on the patient's quality of
life needs to be evaluated. In this case, the likely
outcomes of surgery include death during surgery
or survival with severe permanent neurological
deficits, such as a persistent vegetative state.
These outcomes would significantly impact the
patient's quality of life. The doctor should discuss
these potential outcomes with the family to
ensure they have a realistic understanding of the
potential consequences.
Contextual Features
Considerations in the contextual features include
the patient's medical history, the availability of
resources, legal and institutional policies, and the
involvement of other stakeholders. The patient
has a history of chronic hypertension, which may
have contributed to the hemorrhage. The doctor
should take into account the hospital's policies
regarding surgical interventions in such cases and
the availability of necessary resources.
Additionally, it is important to consider any legal
or ethical obligations that may affect decisionmaking.
2. Determine the conflicts
Description of Conflicts/Issues
Conflicting Ethics Principles/Values
The conflict centers around the family's 1. Autonomy: Autonomy refers to an
insistence on pursuing all possible interventions, individual's right to make decisions about their
including surgery, despite the significant risks
involved. The family wants to prioritize the
preservation of life and the exploration of all
treatment options, even if it could result in worse
outcomes such as death or severe permanent
neurological deficits. On the other hand, the
doctor needs to balance the family's wishes with
the principle of non-maleficence, which
emphasizes avoiding harm to the patient. The
potential harm in this case includes the risk of
death during surgery and the possibility of
surviving with severe permanent neurological
deficits, such as a persistent vegetative state.
own healthcare, based on their own values,
beliefs, and preferences. In this case, the
family's insistence on pursuing all interventions,
despite the risks, reflects their desire to exercise
autonomy on behalf of the unconscious patient.
They prioritize the patient's preservation of life
over the potential negative outcomes associated
with surgery.
2. Non-Maleficence: Non-maleficence is the
principle that emphasizes avoiding harm to the
patient. The doctor must consider the potential
harm that could result from surgical
intervention, such as death during surgery or
surviving with severe permanent neurological
deficits. The doctor has an obligation to weigh
these potential harms against the potential
benefits of surgery, keeping the patient's best
interests in mind.
3. Explore the options
List of All Possible
Options/Alternatives
Surgical Evacuation
of Clot
Strength



Conservative
management
(observation &
monitoring, BP control,
ICP management,
seizure prophylaxis,
nutrition & fluid
management, rehab
and physical therapy,
etc.)


It has the potential to remove
the clot and alleviate the
pressure on the brain,
potentially improving the
patient's condition.
It may prevent further
deterioration and additional
complications
associated
with the hemorrhage.
It aligns with the family's
insistence on pursuing all
possible interventions.
This option avoids the
immediate
risks
associated with surgery,
such as intraoperative
complications or death.
It may be a more suitable
approach if the patient's
overall prognosis is poor
and the potential benefits
of surgery are outweighed
by the risks.
Weakness
There is a risk of death during
surgery, especially considering the
patient's poor GCS score and the size
of the clot.
Even if the surgery is successful,
there is a possibility of severe
permanent neurological deficits,
such as a persistent vegetative state.
The decision to proceed with surgery
needs to be carefully balanced with
the patient's overall prognosis and
potential quality of life outcomes.



Conservative
management may lead to
the progression of the
hemorrhage
and
exacerbation
of
symptoms.
It does not actively
address the source of the
problem (the clot) and
may not
result
in
significant improvement
in the patient's condition.
There is a possibility of
further
neurological
deterioration and long-
term complications.
Palliative Care and
Comfort Measures
(pain management,
symptom control,
emotional &
psychological support,
spiritual & existential
support, assistence with
ADLs, end-of-life
planning, family
support, bereavement
support)



Palliative care focuses on
providing comfort and
symptom management for
the patient.
It ensures that the patient's
end-of-life wishes are
respected, if applicable.
It may be considered if the
patient's overall prognosis
is extremely poor and
further interventions are
unlikely
to
yield
significant benefits.



This option does not
directly
address
the
underlying cause of the
hemorrhage.
It may be challenging for
the family, as they have
expressed a strong desire
for
aggressive
intervention.
It
requires
careful
communication
and
support to ensure the
family's
understanding
and acceptance of the
approach.
4. Action plan
Prioritized Actions
Reason/Justification
Surgical Evacuation of Clot:
This option may be considered if the patient's overall condition and prognosis suggest a
reasonable chance of benefiting from the procedure. Factors to consider include the patient's
age, pre-existing health conditions, size and location of the clot, and the feasibility of the
surgical intervention. If the potential benefits of clot removal outweigh the associated risks,
surgery may be a viable option.
Justification: The justification for recommending surgical evacuation would be based on the
potential to relieve pressure on the brain, prevent further deterioration, and improve the
patient's condition. However, the risks of death during surgery and the possibility of severe
permanent neurological deficits should be carefully weighed against these potential benefits.
Conservative Management:
If the patient's prognosis is poor, surgical intervention may carry significant risks, or the
patient's wishes are unclear, conservative management may be a suitable option. This approach
focuses on supportive care, monitoring, and symptom management to ensure the patient's
comfort and well-being.
Justification: The justification for choosing conservative management would be based on the
understanding that aggressive interventions, such as surgery, may not significantly improve the
patient's outcome or quality of life. Instead, the emphasis is placed on providing comfort,
minimizing suffering, and maintaining the patient's dignity.
Palliative Care:
Palliative care may be considered if the patient's condition is deemed to be terminal or if the
risks and burdens of invasive interventions outweigh the potential benefits. In such cases, the
focus shifts towards ensuring comfort, symptom management, and providing psychosocial and
spiritual support.
Justification: The justification for recommending palliative care would be based on the
understanding that the patient's prognosis is extremely poor and further interventions are
unlikely to provide meaningful benefits. This option respects the patient's autonomy and
prioritizes comfort and quality of life during the remaining time.
Ultimately, the decision regarding the most appropriate option should be made through a
collaborative process involving the medical team, the patient's family, and the patient if
possible. It should be based on a comprehensive evaluation of the patient's clinical condition,
prognosis, values, and preferences. The medical team's expertise, along with open and honest
communication, will be crucial in guiding the decision-making process and determining the
best course of action for the individual patient in this complex and sensitive situation.
CASE 2
Adam is a 12-year-old boy being treated for osteosarcoma of the arm in the paediatric oncology
unit. Although he initially responded well to treatment, he has suffered a relapse and now has
widespread metastatic disease. His parents have been told about his relapse and a further cycle
of chemotherapy, with the hope of prolonging his life by a few months, has been suggested.
The chances of cure are negligible and the side effects likely to be very significant. His parents
have considered the options and decided they would like him to have further chemotherapy.
However, they are adamant that they do not want Adam to be informed that his cancer has
spread or that he is likely to die even with the additional chemotherapy. They wish to protect
him and are very worried that telling him will cause him great distress. The doctor and medical
team has encouraged the parents to involve Adam in decision-making and explained that
families are encouraged to discuss things honestly with their children, even when the prognosis
is terminal. However, his parents insisted on not allowing doctors to disclose the medical
information and prognosis to Adam, and continue making plans with him for the following
year and telling him he needs further chemotherapy to ‘get better’. What should doctor do in
this situation?
Clinical Ethics Worksheet
1. Identify the facts
Medical Indications
Patient Preferences
Adam, pasien berusia 12 tahun, mengidap
osteosarcoma pada lengannya dan saat ini
kankernya telah bermetastasis. Saat ini,
Adam sedang dirawat di unit onkologi
pediatri. Adam telah melewati beberapa
tahap kemoterapi dan direncanakan untuk
mengambil kemoterapi lanjutan. Walaupun
kemungkinan untuk sembuhnya sudah tidak
cukup signifikan, tetapi kemoterapi lanjutan
ini dapat memperlama masa hidup Adam,
setidaknya beberapa bulan.
Keputusan pasien terkait kemoterapi lanjutan
tidak jelas diberitahukan dalam kasus di atas.
Namun, Orang Tua Pasien telah menyetujui
bahwa akan tetap dilakukan kemoterapi
lanjutan meskipun kemungkinan sembuh dari
kanker bisa dibilang tidak signifikan. Orang
tua pasien tidak ingin pasien mengetahui efek
samping dan output dari pengobatan ini agar
pasien tidak putus asa akan penyakit yang
dideritanya. Orang tua pasien hanya ingin
pasien merasa ‘berhasil’ telah melewati
beberapa tahan kemoterapi dan hanya butuh
beberapa kemoterapi tambahan untuk
akhirnya ‘sembuh’.
Quality of Life
Contextual Features
Pada kasus di atas telah disebutkan bahwa
harapan hidup dan kesembuhan pasien sudah
bukan menjadi prioritas utama meskipun
dengan kemoterapi tambahan. Namun,
dengan dilakukannya kemoterapi tambahan
pasien dapat memperlama masa hidupnya
selama beberapa bulan terlebih pasien
Pada kasus Adam, Adam sebagai pasien
tidak memberikan keterangan secara jelas
apakah ia menerima atau menolak
kemoterapi tambahan. Adam juga tidak
diberitahukan pertimbangan-pertimbangan
keberlanjutan
pengobatannya.
Seluruh
keputusan berada di tangan orang tuanya.
memiliki keluarga yang supportif.
2. Determine the conflicts
Description of Conflicts/Issues
Conflicting Ethics Principles/Values
Isu pada kasus Adam adalah tidak terlibatnya
Adam, pasien kanker, dalam pengambilan
keputusan
terkait
keberlanjutan
pengobatannya.
Seluruh
keputusan
pengobatan Adam berada di tangan Orang
tuanya tanpa sepengetahuan Adam sendiri.
Konsep shared decision making process
tidak terlaksana sepenuhnya disini.
Kebimbangan terjadi antara apakah harus
tetap tidak melibatkan pasien dalam
pengambilan keputusan pengobatan sesuai
dengan
keinginan
keluarga
pasien
(mementingkan aspek beneficial dan
paternalism) atau tetap melibatkan pasien
dalam mengambil keputusan meskipun
keluarga pasien tidak menyetujuinya
(mengedepankan aspek autonomi dan
pelaksanaan decision-making yang baik).
3. Explore the options
List of All Possible
Options/Alternatives
Strength
Weakness
Tetap tidak melibatkan Pasien tetap merasa memiliki Pasien
tidak
diberikan
pasien
dalam
proses harapan hidup dan less stress. kebebasan memilih terutama
decision-making.
hal yang berkaitan dengan
kesehatan
dan
keberlangsungan hidupnya.
Hak
autonomi
pasien
dikesampingkan.
Melibatkan pasien dalam Pasien memiliki kesempatan
proses decision-making.
untuk mengambil keputusan
yang
berkaitan
dengan
keberlangsungan hidupnya.
Meskipun dalam kasus ini,
pasien masih di bawah umur,
pasien tetap memiliki hak
autonomi akan tubuh dan
hidupnya sendiri.
Ketidaksiapan orang tua/wali
pasien akan keputusan yang
diambil pasien tidak sesuai
dengan harapan mereka.
4. Action plan
Prioritized Actions
Melibatkan pasien dalam proses decisionmaking.
Reason/Justification
Meskipun Adam masih di bawah umur,
Adam masih memiliki hak autonomi dan
hak asasi manusia terkait tubuhnya sendiri.
Adam mempunyai hak untuk tahu
keberlangsungan pengobatannya akan
seperti apa.
Peran tenaga kesehatan dalam kasus seperti
ini adalah menjelaskan hal-hal yang
berkaitan dengan kondisi kesehatan pasien
sesuai dengan kapasitas pemahaman pasien
beserta keluarga. Tenaga kesehatan juga
harus bisa menjelaskan apa saja pros dan
cons dari seluruh opsi yang dapat diambil
kedepannya. Hal ini diperlukan untuk
meminimalisir miskomunikasi antara tenaga
kesahatan, keluarga pasien, dan pasien itu
sendiri serta agar shared decision-making
terlaksana dengan baik.
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