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Station Name: Candura
Issue:
Decisions to Forgo Treatment
Presenting Situation:
Albert Whiteside has gangrene in his right leg and it is recommended that it be amputated. Mr. Whiteside is refusing to have the operation even though the decision will in all likelihood lead shortly to his death.
Activities:
Patient encounter.
Time Required:
10 minutes
This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.
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Instructions to Candidate:
You are about to see Albert Whiteside. Mr. Whiteside was diagnosed as a diabetic 3 years ago. He is suffering from gangrene in the right foot and lower leg. A week ago it was recommended that his leg be amputated (below the knee) without delay. At first Mr. Whiteside agreed to the amputation. On the morning scheduled for the operation, he refused to give consent. He left the hospital to stay with his daughter for a few days, but now he is back in hospital.
Earlier today, the intern spoke to Mr. Whiteside and fully explained the diagnosis, prognosis with and without intervention, and the risks and benefits of operating and the patient seemed to understand. However, he refused to consent to the operation even though that decision will in all likelihood lead shortly to his death.
You are the resident currently in charge of his care. Your staff person has asked you to speak to Mr. Whiteside about having the operation.
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CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^
YES NO The Candidate:
1. asks why patient does not want operation
(amputation) (e.g. "What's your
concern?").
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2. asks about patient's mental/emotional
state (i.e. is patient depressed or
suicidal).
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3. gives information about problem with leg
and ascertains that patient understands.
----|-----------------------------------------------------------
4. gives information about use of
prosthetic limbs following surgery.
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5. ascertains that patient understands
consequences of decision (i.e. that he
may die without amputation).
----|-----------------------------------------------------------
6. asks about the presence of other
involved persons (e.g. family, children,
etc.).
----|-----------------------------------------------------------
7. agrees to respect patient's decision
(e.g. states that patient has right to
refuse operation, and/or that decision
to amputate is his).
----|-----------------------------------------------------------
8. asks if patient will consent to other
life-sustaining therapies (e.g. CPR,
antibiotics, etc.).
----|-----------------------------------------------------------
9. states that patient can change mind (but
only to a point, after which decision
becomes irreversible).
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=================================================================
RATE FROM 1-5:
+------------------------------------------------------------+
| | | | VERY | |
| POOR | FAIR | GOOD | GOOD | EXCELLENT |
| 1 | 2 | 3 | 4 | 5 |
+------------------------------------------------------------+
1. How would you rate the candidate's communication skills?
1 2 3 4 5
2. How would you rate the candidate's ability to address the
ethical issue in this case?
1 2 3 4 5
___________________
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