- Too Much To Ask?
A seventy-eight-year-old Chinese man is admitted to the hospital with a cerebral hemorrhage. Over the course of several weeks, his neurosurgeons repeatedly discuss his poor prognosis with his family, advising them to consider abandoning aggressive intervention in favor of comfort care. The only family member who speaks English is the man’s son, who is a physician. He translates for the rest of the family, but whether they understand the gravity of the situation is unclear, as they interpret any sign of movement as a hopeful event.
Eventually, after the man’s family has tried a traditional Chinese herbal remedy that hasn’t worked, a palliative care consultation is held in which they are again asked if they would consider discontinuing the catheters and ventilator. They seem agreeable, but they wish to consult with other family members before giving a final answer. After more time goes by, the team requests an ethics consultation with a translator present. It becomes clear that the family has understood neither the gravity of the situation nor the concept of comfort care. The family asks whether, if they agree to comfort care only, the man’s body can remain untouched for eight hours after his death to conform to their Buddhist faith, which dictates that the deceased’s body should remain undisturbed for a period of time after death to allow the soul to exit the body. On being assured that this wish will be honored, the family agrees to a “do not attempt resuscitation/do not intubate” order. The patient dies shortly thereafter. Because the death occurs so quickly, there is no time to move the man out of the intensive care unit as had been planned, but the family’s request to leave the body undisturbed is nevertheless accommodated.
During the time that the body is in the ICU, another physician attempts to get an acutely ill patient with severe gastrointestinal bleeding admitted, but a bed is not available. As a result, this patient must be directly admitted to the cardiac catheterization suite. (Neither the medical team caring for the Chinese man nor the hospital’s ethics consultation service were aware that another patient needed the ICU bed.) Several days later, the physician who tried to admit the patient discovers that a corpse was occupying a bed in the ICU. He is incredulous. Can we justify allowing a body to occupy a bed needed by a living patient?
Our country values religious freedom and is unique in its ethnic diversity. In spite of this, medical facilities have been slow to adopt culturally and religiously diverse approaches to patient care and end-of-life issues. However, in recent years, treatment teams have received additional training in cultural sensitivity, and if a cultural practice can be accommodated in the course of treatment, this is encouraged, as it builds rapport and recognizes the patient as an individual. Chaplain services are also widely available, and many faiths are now represented. Hospitals attempt to accommodate other types of requests as well, whether they are religious or cultural. For example, in our community, it is not uncommon for Muslim women to request a female practitioner for intimate examinations or for family members to ask that patients not be told of their terminal diagnoses to preserve hope.
This case is unique in several respects. One could argue that the needs of the deceased took precedence over those of a critically ill living patient. In this type of situation, our societal and cultural values would support a different course of action in which we prioritize the sick; only once this has occurred can we focus on spiritual needs. However, this man’s family agreed to withdraw care under this specific condition. If the condition had not been accommodated, the patient might still be alive and occupying the bed.
The team made a promise to the family, so it would be difficult to justify a different course of action after death. As Robert Veatch has written, the principle of fidelity maintains that promises are a type of contract that should be honored. Beauchamp and Childress...