'Who is Responsible for this Patient?': A Case Study Analysis of Conflicting Interests between Patient, Family and Doctor in a Singaporean Context

Case Summary

Mdm KL was a previously well 46-year-old female who was admitted for complaints of progressively worsening headaches over six months. There were no other neurological symptoms. Despite the usual treatments, her symptoms remained refractory. An MRI (Magnetic Resonance Imaging) of her head demonstrated a lesion in her left temporal lobe.

In view of these findings, the patient was referred to the Department of Neurosurgery. The clinical impression was that of a primary brain tumour, possibly an aggressive glioma. A conference was held between Mdm KL, her husband and the neurosurgical team. No other family members were present. The doctors explained the current standard treatment: surgical excision of the lesion, followed by adjuvant chemotherapy and radiation therapy if the lesion was high-grade. The only way to confirm the tumour grade was via intra-operative histology of the excised lesion. If the lesion was indeed high-grade, she was recommended to undergo a course of concurrent radiotherapy and chemotherapy within six weeks post-surgery. She agreed to proceed with the full course of treatment, and signed her own consent for the operation with her husband present. He showed support for her decision.

The planned surgery was uneventful. A routine post-operative MRI brain demonstrated adequate excision of her brain tumour. She was transferred to the general ward on the day after her operation.

However, on post-operative Day Four, Mdm KL developed serious pneumonia. She was re-admitted to the Neurointensive Care Unit, given ventilatory support and high-dose intravenous medications. During this period, her older brother who claimed to be a Traditional Chinese Medicine (TCM) physician made an appearance. He expressed great unhappiness with the medical team, blaming the doctors for the patient's deterioration.

The final histology of the tumour confirmed a high-grade glioma. Approximately three weeks post-surgery, Mdm KL recovered from her pneumonia. However, it was noted that her cognitive status had declined. Though she was able to participate in simple conversations, she was not able to comprehend the full extent of her illness or treatments needed. The doctors attributed this to possible post-operative brain swelling and a recent bout of sepsis. They felt her symptoms were likely to improve with time. Her husband was then approached for allowing adjuvant therapies to commence.

The patient's husband informed the medical team that the main decision-maker was now Mdm KL's brother. Hence, they should speak to the latter regarding further treatment plans for the patient. When spoken to, the brother adamantly refused for adjuvant therapy to start. His decision was backed by the patient's parents. They wanted the patient to be "better" as they felt she was "too weak" at this stage. Furthermore, the brother insisted on some goals for her to achieve as priority. These included a weight gain of about 10kg, and for her to return to her previously high-functioning status before her illness.

Multiple attempts were made to re-explain the need for further treatment to give Mdm KL the best chance of survival. Her husband was also simultaneously approached, but he remained subservient to his brother-in-law's decision. In addition, the hospital engaged its medical social worker to be involved in the discussions. However, all efforts were unsuccessful.

The allied health team, which included a dietician, speech therapist, physiotherapist and occupational therapist, was engaged by the medical team to attend to the patient. This was an attempt at trying to help accelerate her recovery process to at least meet the brother's demands as much as possible. However, her general and cognitive function failed to improve.

As time passed, the patient became increasingly drowsy and uncommunicative. An urgent MRI brain demonstrated aggressive tumour recurrence with local invasion into surrounding structures and dissemination into her spinal cord. The family was duly informed of the imaging findings. They were also informed that repeat surgical intervention or adjuvant therapy at this stage, would not be helpful. Overall, her prognosis was grim.

Mdm...