Centre for Biomedical Ethics at the Yong Loo Lin School of Medicine

Making Difficult Decisions with Patients and Families

A Singapore Bioethics Casebook

An Introduction

CASE STUDY

Baby Arun

This case concerns an extremely premature, critically-ill newborn. It explores prognostic uncertainty in the neonatal ICU setting, and the challenge of communicating frequently-changing medical information while providing support to the baby’s parents and other concerned relatives.

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Baby Arun

CASE STUDY

Faizal

This case concerns an undergraduate whose traumatic brain injury results in locked-in syndrome. His doctors, nurses, and home carers must meet the challenges of understanding his wishes, while coping with repeated hospitalisations.

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Faizal

CASE STUDY

Lina

This case concerns an adolescent with recurrent leukaemia, and physician-parent conflicts over her treatment plan. It explores the rights of the adolescent patient and the possibility, consequences and ethics of seeking judicial intervention in the best interests of a child.

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Lina

CASE STUDY

Mrs Kuan

This case concerns a middle-aged professional and parent with metastatic cancer for whom potentially beneficial, highly expensive treatment has failed. It explores clinical uncertainty over how to discuss the goals of care when few options for effective treatment exist.

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Mrs Kuan

CASE STUDY

Mr Lim

This case concerns a middle-aged hawker’s assistant with severe and progressively worsening arthritis who relies on steroids and other anti-inflammatory medications to enable him to continue to work, but is suffering from the chronic and potentially life-threatening side-effects of the long-term use of these drugs. His polyclinic doctor is challenged to understand the coping strategies of her patient and how best to advocate for him.

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Mr Lim

CASE STUDY

Mr Bok

This case concerns a middle-aged professional and single parent whose multiple health problems are exacerbated by his smoking and alcohol use, and who is viewed as a ‘difficult’ patient by hospital and clinic providers. The patient’s health problems could be alleviated by transplant surgery, but the hospital staff is uncertain whether this patient will adhere to the post-transplant regimen.

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Mr Bok

CASE STUDY

Mrs Khoo

This case concerns a single parent with a previous history of drug addiction who has completed a programme of drug rehabilitation and is working in a halfway house. The patient is seeing her GP periodically as follow-up to specialist treatment for hepatitis. The patient’s mother, who helps with childcare while her daughter is at work, phones the GP with a problematic request.

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Mrs Khoo

CASE STUDY

Ms Mendez

This case concerns a foreign domestic worker hospitalised for diagnosis and treatment of suspected pneumonia. Her health insurance coverage is likely to run out before she can be safely discharged, and her doctors are uncertain about this patient’s options and their responsibilities as advocates.

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Ms Mendez

CASE STUDY

Mdm Lee

This case concerns an elderly nursing home resident with advanced Alzheimer’s disease who, while she was competent, completed an advance care plan that documented her explicit refusal of artificial nutrition and hydration. Confusion and family conflict arise after a staff member makes an ad hoc decision to insert a nasogastric tube.

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Mdm Lee

CASE STUDY

Mr Shi

This case concerns an elderly retired businessman who has long been concerned that he would develop Alzheimer’s disease, who had expressed general preferences about his future medical care to his eldest son, and who has now developed some memory problems. When the patient’s GP diagnoses a comorbid medical condition, the patient is referred to a specialist. His son and other family members are uncertain how decision-making about treatment for this condition should proceed.

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Mr Shi

CASE STUDY

Mr Yung

This case concerns a middle-aged professional and parent in a minimally-conscious state, his wife’s emotional and practical challenges in making decisions on behalf of her catastrophically injured spouse, family conflict, and the responsibilities of the healthcare team.

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Mr Yung

CASE STUDY

Mdm Wu

The case concerns an elderly retired teacher with decision-making capacity who leaves decision-making to her eldest son after she declines surgery to repair a fractured hip. Conflict erupts between the eldest son, who lives overseas, and his sister, who is their mother’s main caregiver. The healthcare team must resolve the conflict while addressing the caregiver’s concerns about whether the care plan reflects an informed decision.

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Mdm Wu

Volume I of the Casebook, Making Difficult Decisions with Patients and Families is a free and open-access online resource for continuing professional education in healthcare ethics for doctors, nurses, and allied healthcare staff. Each case is supported by expert commentaries highlighting ethical issues and a clinical perspective by a healthcare professional offering practical insight. Additional support is provided by informational backgrounders, questions for reflection, and further online resources.

The characters that appear in the Casebook are fictitious and modelled for teaching and learning purposes on the basis of common clinical encounters described by healthcare professionals, and do not refer to specific, real individuals, living or dead. Any individuals appearing in photographs depicting these characters bear no relationship or connection whatsoever to the stories ascribed to those characters.

Quotes from Physicians

“The casebook is particularly useful as a learning tool to increase our exposure to these difficult situations in the local setting, and help to prepare as well as instil confidence in tackling such problems.”

—Dr Lisa Anne Wong, Medical Resident in Paediatrics

“This is a valuable resource for residents at all stages. It's very helpful to read the expert commentaries and think through the various ethical frameworks that were used."

—Dr Lydia Wong, Medical Resident in Paediatrics

“Ethics is an integral aspect of medical practice. How can we help families accept the reality of the dying child? With money, of course, you can give everything that families may want. But what is the ethical thing to do?”

—Dr Tan Poh Lin, Paediatrician

“Patients and caregivers value meaningful conversations, especially about our beliefs and faiths, especially how that would impact their feeling of general well-being. So if you want to carry on a conversation about comfort, then put it to them but also respect their own volition and beliefs.”

—Dr Ramaswamy Akhileswaran, Hospice Director

“How would you manage a typical eighty-year-old patient with chronic disease and memory loss? Not everything is, “See, and refer the patient onward.” Then you don’t develop yourself as a doctor. We start by teaching the junior doctors, and it’s like an apprenticeship.”

—Dr Yehudi Yeo, Family physician, NHG Polyclinics

“7 out of 10 students in our medical school have seen how the poor in Singapore live. We say: when someone is not adhering to your lifestyle advice or medication, know the context of his struggles, and you'll understand why.”

—Dr Gerald Koh, Family Physician and Community Geriatrician

Making Difficult Decisions with Patients and Families

A Singapore Bioethics Casebook

Baby Arun

Faizal

Lina

Mrs Kuan

Mr Lim

Mr Bok

Mrs Khoo

Ms Mendez

Mdm Lee

Mr Shi

Mr Yung

Mdm Wu

Quotes from Physicians

Before you read the Casebook...

Teaching and Learning Guide

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