The patient at thecentre of this study I will call Mrs Thomas, this is not the patient’s realname. Case based discussions (CBD) are a very important assessing tool for futurepurposes as it gives us an insight into how our patients may be feeling. Thisgives us an opportunity to empathise when facing similar situations in thefuture and prove our capability to care for patients. As quoted by theIntercollegiate surgical curriculum programme (ISCP), “CBD is designed toassess clinical judgement, decision making and the application of medicalknowledge” (ISCP, 2010). It allows us to analyse why our patients react the waythey do. Patient BackgroundMrs Thomas is a 52-year-oldwoman who suffers from angina. She is a smoker and has admitted to smoking atleast a pack a day for a year, this is the equivalent of one pack year.
A packyear is defined as “a term used to express theamount of smoking exposure a person has had over time” (Nursing Times, 2015). She lives with her husband and has a daughter who’smarried and lives elsewhere. Neither her or her husband can drive and herdaughter is currently 6 months pregnant. Mrs Thomas is currently overweight andhas been advised by her GP to adopt a healthier lifestyle since she has a familyhistory of heart disease. Because of this she has attempted to stop smoking. Shealso suffers from hypertension; hypertension is high blood pressure. This isdescribed as “elevation of the arterial blood pressure above the normal rangeexpected in a particular age group” (Oxford Concise Medical Dictionary, 2015).
She is currently taking an angiotensin-converting enzyme inhibitor (ACE) tolower it along with a diuretic. Supposedly “ACEinhibitors inhibit or limit this enzyme, making your blood vessels relax andwiden” (British Heart Foundation, 2018), the enzyme mentioned is theangiotensin-converting enzyme. Because of this the blood pressure drops.
She also suffers from high cholesterol and is onstatins to control it. High cholesterol is one of the many risks for heartdisease. According to the British Heart Foundation “too much bad cholesterol (LDL) in your blood cancause fatty material to build up in your artery walls” (British HeartFoundation, 2018). This can later lead to atherosclerosis which is defined as “a disease in which plaque builds up inside your arteries” (NationalHeart, Lung, and Blood Institute, 2018). When the atherosclerosis is in thecoronary arteries it’s classed as coronary artery disease. She claims that she doesn’t move around a lot at homeas she hasn’t had a lot of housework to do since her daughter moved out.
Shegets short of breath and the chest pain gets worse on exertion. She has had anangiogram where it was revealed that there was too much narrowing to fit astent. It was decided that a coronary bypass would be the best option. There isa worry that without the surgery she has a very good chance of myocardialinfarction that could then lead to a cardiac arrest. Overview of caseWhen getting readyfor the coronary bypass surgery Mrs Thomas met with the surgeon that would bedoing the procedure. Her husband and daughter were by her side and she wassitting on the bed. The surgeon, who was a man, introduced himself andexplained the procedure clearly to Mrs Thomas. He asked if she had anyquestions at all and if she felt comfortable doing the procedure.
He explainedthe importance to her of the surgery and why she should have it. Upon realisinghe would be the one to do the surgery, Mrs Thomas looked uncomfortable. When hefinished speaking she explained that she didn’t feel comfortable with him doingthe surgery as he was a man. He then explained to her that there were no femalesurgeons who had experience in the coronary bypass surgery now and that he wasthe only one available. She decided that she did not want to have the surgeryif he was going to do it. She believed that she would feel extremelyuncomfortable since he would need access to her chest and that it was againsther beliefs.
The doctor tried to reason with her and explain that this surgerywas important and that there was a very high risk of her having a cardiacarrest without it however she was not concerned about this at all. The surgeonclearly looked dissatisfied with her decision. She continued asking for afemale doctor instead and so the doctor went to see if there was anything theycould do. The surgeon came back and explained that if she was not going to havethe surgery she would have to go to the back of the waiting list. She continuedto refuse to have the surgery and started to insist that they let her go home. Sherefused to consent to the procedure. The surgeon decided to give her some timeto think about it and speak to her family about it.
She seemed very stressedand adamant that she didn’t want the surgery. This caused great worry to thedoctors as they were very concerned about her suffering myocardial infarctionand possibly a cardiac arrest. She kept telling her husband that she wanted toleave and he was attempting to reason with her which just made her even morefrustrated. Her daughter seemed very distressed during this situation. DiscussionThis situation isextremely difficult for all parties involved. This surgery is consideredlife-saving for her as her coronary arteries are so blocked up and she will diewithout it.
The fact that it needs to be pushed back for so long could meanfurther damage to her heart and possibly death. The family must feel extremelyworried and frustrated with the patient knowing that she is doing something sodangerous. However, showing that they feel frustrated could anger Mrs Thomasand put her under more stress than she already is. Perhaps they feel like it’s unfair that thesituation has turned out the way it has. This could also lead to them blaming theheath service for not having more female surgeons that can perform the surgeryeven though the health service shouldn’t be blamed as there is nothing they cando. They may also feel frustrated withMrs Thomas as she is holding her discomfort and beliefs more important than thesurgery when they believe her life is more important. They may also feelpowerless as they desperately want her to be healthy and well but cannot seemto change her mind on the surgery. It could possibly lead to falling out in thefamily which could lead to the patient being under more stress than she needsto be.
It may worry Mrs Thomas a lot that her daughter is so distressed as sheis currently pregnant, it may cause more stress and upset again. Ideally, theydon’t want her to be under stress for the sake of her heart. The fact that shewill not give consent for the surgery must be very frustrating for the doctorsas they know how important it is. However, they must respect her wishes. Theonly thing the doctors can do is give medical advice, they will not be allowedto force her into any procedure and so it’s extremely frustrating for them.They probably feel very concerned for her well-being and just want her to feelbetter.
Legally, she is also able to make whatever decision she wants. TheMental Capacity Act (2005) says a person “should not be assumed to lack thecapacity to make a decision just because other people think their decision is unwise”(Mental Capacity Act, 2005). The General MedicalCouncil say, “You must respect a competent patient’sdecision to refuse an investigation or treatment, even if you think theirdecision is wrong or irrational” (General Medical Council, 2013). Using these,Mrs Thomas must be allowed to make her own decision and refuse treatment. Sinceshe is refusing because of her beliefs and not because she does not understandwhat is happening we know that she has the mental capacity to make her owndecisions. According to Rethink Mental Illness “Mentalcapacity is the ability to make your own decisions” (Rethink Mental Illness,2014). She doesn’t have any mental illness or learning disability that wouldstop her from deciding whether to have the surgery.
Therefore, without consentfrom her the surgery cannot happen and must be moved until there is a female surgeonavailable. Patient perspective MrsThomas is feeling extremely frightened in this situation due to the fact it isa very big surgery and it will have a massive effect on her physically andperhaps mentally. She is probably feeling very anxious as she could possibly befeeling like she won’t make it through the whole surgery. This could also bethe reason why she isn’t as worried about pushing the surgery back as she mayfeel like risking it is less scary. These feelings could be the reason for herignoring the importance of the surgery. In general, Mrs Thomas may be worryingabout what would happen to her daughter and would she be able to see hergrandchildren. She could also be worrying about her husband and how he wouldcope if she had to stay in the hospital for a while after the surgery as hecannot drive and her daughter would be working. Perhaps the discomfort of beingexposed to a male doctor has added to the feelings of fear and anxiety and hassent her over the edge.
She could be feeling disrespected because the doctorsclearly don’t agree with her beliefs. She probably also feels betrayed in someways as her family are agreeing with the doctor and want her to get thesurgery. Mrs Thomas probably understands that they are only trying to reasonbecause they care and want her to be healthy however she probably feels pushed.
There is a chance that Mrs Thomas may be using the idea of discomfort as anexcuse for why she doesn’t want the surgery when it’s really because she’safraid of having it done. Perhaps this is because she feels embarrassed aboutshowing her actual feelings in front of her family and wants to be brave forthem. She may find it easier to admit that she is uncomfortable with beingtreated by a male surgeon rather than she is worried and anxious about theprocedure. Her personality might not allow her to admit her fear and so thismay be her way of keeping her dignity.
She may also feel bad that she isputting her family through this and may feel like she is wasting their time.She may also feel frustrated that the doctor is still trying to reason with herwhen she has already said that she doesn’t want the surgery. She probably knowsthat the surgery is important for her health but in the heat of all thenegative feelings she is unable to reason very well and the fear is takingover. Mrs Thomas could probably do with more time to accept the surgery andcalm down.
If she was to get a female surgeon then she would feel less anxiousand more respected. This will mean she will be able to recover better. Conclusion Inconclusion, Mrs Thomas must be allowed to refuse the bypass surgery and shewill be added to the waiting list once again for a female surgeon to performthe surgery. She will have to make drastic changes to her lifestyle immediately,start on stronger medications and be very careful with her heart as she isdangerously susceptible of having a cardiac arrest. This may mean that herfamily could possible feel on edge however it will give Mrs Thomas more time toget used to the idea of having the surgery and in the end, she will feel morecomfortable.