Ethical Dilemmas

She was a new admit to the cancer ward.  From the brief history I could get from the house officer, she had a history pancreatic cancer (not sure what stage, not sure what her DNR status would be) and was coming in for change in mental status.  "Change in mental status" was a bit of a euphemism.  She was actually completely obtunded, unresponsive with eyes open.  Her attendant could only tell us that the day previously she ate lunch without incident and then was no longer herself.  Her blood pressure and oxygen saturation were too low to be measured.  Her hands and feet were ice cold. When we initially examined her, she would swat our hands away.  And then she stopped breathing.  In any other setting, this would be reason to call a code.  She did resume some form of breathing on her own.  I asked the house officer about transferring her to a higher level of care/monitoring but was told that this patient would not meet criteria for being in the ICU (I'm still trying to figure out exactly how close to death you have to be to get into the Mulago ICU).  Besides, we were in Old Mulago and the ICU is in New Mulago which is about 1/4 of a mile away with no easy way of transporting her over there.

In that moment, perhaps the house officer saw what I could not.  I was looking at the immediate need:  If someone stops breathing or if they do not have the proper circulation, you FIX it.  Especially when the patient was doing 'well' and ate lunch with her family just yesterday.  But in looking at the 'long' term, you have a patient with a diagnosis that carries a poor prognosis AND she is in a resource deprived setting.  So do you try to make this person better or do you preserve the few resources that you have? In this particular case, the house officer gave her fluids and antibiotics.  She died that night.

In addition to allocation of resources, the other dilemma that arises frequently is the reluctance to have frank discussions with patients about their prognosis.  For example, a renal failure patient needed dialysis.  Dialysis is expensive.  The patient's family sold land, property and possessions to pay for 5 sessions of dialysis.  Since dialysis is a lifelong need, what do you do when it is time for sessions 6 through infinity? So how do you counsel the family who is selling all of their possessions for 5 sessions of dialysis??