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CASES

FINDING THE KEY

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TODD Z. I[INFORMED CONSENT]

• Todd Z. is a 75-year-old male who has been diagnosed as having lung cancer with brain metastases. His physician of thirty years, Dr. S., is seriously concerned that, if told of his diagnosis, Todd Z. will go into a deep depression and spend the remainder of his life in that state.

• SHOULD DR. S.’S CONCERN ABOUT DEPRESSION INTERFERE WITH THE DYNAMICS OF INFORMED CONSENT?

• WHAT COULD BE DONE TO MITIGATE THE IMPACT OF “DEPRESSION” ON INFORMED CONSENT?

• SHOULD DR. S. BE HELPING TODD Z. MAKE DECISIONS ABOUT FUTILE CARE?

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TODD Z. II• Dr. S. keeps the information from Todd Z. and orders Todd Z.'s

wife and three sons not to tell the patient of the diagnosis. He claims that "deep down" Todd Z. would not want to know about his diagnosis. He tells them that he wants to keep the patient in the hospital for a couple of weeks for brain radiation and promises to make up some excuse for the treatment. After the treatment is concluded, the family can take him home to die.

• IS IT APPROPRIATE, OR EVEN ACCURATE FOR THE PHYSICIAN TO GUESS WHAT THE PATIENT WOULD WANT?

• IS IT APPROPRIATE TO STOP COMMUNICATION BETWEEN THE PATIENT AND HIS FAMILY?

• IS TODD Z.’S SELF-DETERMINATION IN JEOPARDY?

• WHAT IS THE QUALITY OF THE FIDUCIARY RELATIONSHIP AT THIS POINT?

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TODD Z. III• Dr. S. promises that he will visit Todd Z. at his home

every week and care for him until he dies because he has been very fond of him and lives nearby. Todd Z. becomes increasingly persistent with his questions about his physical condition. By the third week the family breaks down and tells him about the diagnosis. Todd Z. does go into the predictable depression, but it is not as severe as Dr. S. had feared.

• IS TODD Z.’S PERSISTENCE AN INDICATION THAT HE WANTS HIS VALUES TO BE INCORPORATED IN ANY DISCUSSION ABOUT HIS CONDITION AND TREATMENT?

• COULD THIS PERSISTENCE LEAD TO A DISCUSSION ABOUT THE FUTILITY OF HIS TREATMENTS?

• WAS IT APPROPRIATE FOR THE FAMILY TO GO AGAINST THE PHYSICIAN’S DIRECTIVE?

• WHAT COULD BE DONE ABOUT TODD Z.’S MENTAL STATE?

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TODD Z. IV• Dr. S. is angered by the fact that the family has

disobeyed his orders. He releases Todd Z. from the hospital and does not keep his promise to visit him at home. He never visits him during the six-month period from Todd Z.'s departure from the hospital to the day of his death. During that six-month period Dr. S. is very uncooperative. When the family contacts him to discuss the medication program, he is very curt with them, and when they ask him about a particular condition that is developing, he insists that they will have to bring Todd Z. to the office or to the hospital. He even refuses to talk with the patient on the telephone.

• WHAT IS THE QUALITY OF THE FIDUCIARY RELATIONSHIP NOW?

• DOES DR. S.’S ATTITUDE TOWARD INFORMED CONSENT REVEAL A DEEPER PROBLEM IN HIS CHARACTER?

• HOW HAS DR. S.’S ATTITUDE TOWARD INFORMED CONSENT, AND HIS PROFESSIONAL ATTITUDE TOWARD TODD Z., INHIBITED MR. Z. FROM MAKING ANY DECISIONS ABOUT THE FUTILITY OF HIS TREATMENT?