Con­sul­ta­tion, treat­ment hinges on wishes of pa­tient, not fam­ily

Cape Breton Post - - In Memoriam / Advice / Games - Keith Roach

Dr. Roach re­grets that he is un­able to an­swer in­di­vid­ual letters, but will in­cor­po­rate them in the col­umn when­ever pos­si­ble. Read­ers may email ques­tions to ToYourGoodHealth@med.cor­nell.edu or re­quest an or­der form of avail­able health news­let­ters at 628 Virginia Dr., Or­lando, FL 32803. Health news­let­ters may be or­dered from www.rb­ma­mall.com.

DEAR DR. ROACH: I have al­ways ac­cepted that even in the least in­va­sive sur­gi­cal pro­ce­dure, death could oc­cur. I also am aware of the HIPAA reg­u­la­tion and that pri­vacy is of the ut­most im­por­tance. But to ex­clude im­me­di­ate fam­ily from a con­sul­ta­tion with the pa­tient and a sur­geon on life­and-death is­sues should never be al­lowed. A pa­tient who is close to not sur­viv­ing ob­vi­ously is not in a po­si­tion to make de­ci­sions on his or her own. A con­fi­den­tial con­sul­ta­tion be­tween pa­tient and sur­geon should never, ever be al­lowed. Your opin­ion? -- C.R.

AN­SWER: I wish I knew more about what ac­tu­ally hap­pened in your sit­u­a­tion. Since I don’t, I can say only that if the pa­tient has the ca­pac­ity to make a de­ci­sion, it is the pa­tient’s opin­ion, not a fam­ily mem­ber’s, that mat­ters.

I cer­tainly agree that if a pa­tient wants fam­ily mem­bers to be part of the dis­cus­sion, they should be in­cluded. A sur­geon never should ex­clude a fam­ily mem­ber whose pres­ence is wanted by the pa­tient. I also en­cour­age pa­tients to have their fam­ily mem­bers present for im­por­tant dis­cus­sions with any provider, as life-and-death de­ci­sions are made by care­givers other than sur­geons.

If the pa­tient -- due to med­i­cal con­di­tion, cog­ni­tive im­pair­ment or any other rea­son -- is not ca­pa­ble of mak­ing the de­ci­sion, then a sur­ro­gate de­ci­sion-maker, usu­ally a fam­ily mem­ber, should be iden­ti­fied. This isn’t al­ways as straight­for­ward as it sounds. Some­times it isn’t clear if there is de­ci­sion-mak­ing ca­pac­ity. The pa­tient or fam­ily may feel there is ca­pac­ity, when there isn’t, or vice versa. That’s why the con­text of your ques­tion is im­por­tant and why there is a need for clin­i­cal judg­ment and some­times the need to de­lay things and get help sort­ing it out if there is a con­flict be­tween the pa­tient’s wishes and the fam­ily’s wishes, af­ter med­i­cal ad­vice. When the pa­tient is able to make an in­formed de­ci­sion, how­ever, there isn’t a con­flict, even if the fam­ily (or the doc­tor) dis­agrees.

I spoke with my col­league, Dr. Joseph Fins, di­rec­tor of med­i­cal ethics at Cor­nell, who ad­vises hav­ing ad­vance di­rec­tives to iden­tify the pa­tient’s pref­er­ences, as well as a per­son with durable power of at­tor­ney for health care, to whom doc­tors are obliged to pro­vide in­for­ma­tion when the pa­tient lacks ca­pac­ity, and whom the doc­tors should in­volve if a pa­tient is in ill health and stressed, and gives per­mis­sion.

DEAR DR. ROACH: My daugh­ter has two boys, and both of­ten get colds with runny noses. One of them has a very large amount of mu­cus. How is it that some bod­ies make so much more mu­cus than others? -- N.W.

AN­SWER: Adults make a lot more mu­cus than you might think -- up­ward of a liter (or a quart) per day. It nor­mally is swal­lowed with­out our be­ing aware of it, or it comes out the nose in large quan­ti­ties when the nasal pas­sages are con­gested or when the mu­cus is thick­ened and in­creased in quan­tity due to in­fec­tion.

Why does one boy seem to pro­duce more than the other? Pos­si­bly he gets more con­ges­tion in a cold, forc­ing more to go through the nos­trils. Older boys prob­a­bly make more, too.

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