Case Study – I Know What You’re Thinking

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Case Study: I Know What You’re Thinking

By Diane Deese and Pat Tadel

An African American male patient, age forty-two, was admitted to a skilled nursing unit after surgery for head and neck cancer with lymph involvement, newly diagnosed. Extensive excision of the tumor had been done, and the patient had a newly placed tracheostomy and feeding tube. His history included years of “living on the street” and active drug abuse at the time of admission. The patient was very anxious on assessment, focused on his tracheostomy, pulling on the connections, to “make sure they are working” and complaining of pain “eight-to-ten” on a scale of one-to-ten, with intensity focused in the area of his surgical wounds.

Although he receives morphine on an “as needed basis,” he waits as long as he can to “ring the nurse” because he worries that asking for pain medication will “label him” with the staff. He also complains about not getting much sleep and thinking often of the poor choices that got him “into this trouble.” He has anxiety related to “breathing through this tube, like I am not getting enough air in,” and ongoing pain, which “gets less but never gone.” He readily admits to “risky behavior,” which had alienated him from family and social support for some time and is willing to discuss his years of drug and alcohol abuse.

When the nurses and the attending physician describe the patient’s condition, they explain that his anxiety is “probably related to being a druggie” and that his pain is mostly “drug seeking” in nature, as evidenced by his “calling for more medication a few times a shift” and that he seems to “watch the clock.” They also note that this patient is a “homeless street person” who waited too long to seek help: he hasn’t held a job for some time, has no visitors, and is probably using his illness to feed his addiction.

Questions for Reflection and Discussion

1. How does this man’s history as recorded in the chart affect every encounter he has with healthcare professionals? What is presupposed by his “life on the streets”? by his active drug use in the past?

2. How is even his hesitation to ring the bell for more morphine interpreted on the basis of his past? What other behaviors do the nurses cite as evidence for this judgment? How does the patient explain his behavior? Is any consideration given to the possibility that what is past is past?

3. If a nurse were to walk into this patient’s room without any knowledge of his past, how would his waiting to receive further medicine be interpreted? His not having any company? His anxiety about his condition?

4. Review the articles and the timeline in this issue. How would knowing something about the history of pain management change the way we treat this patient?

5. Suppose that this case was brought to you for an ethics consultation. Are concerns about the patient’s pain relief being “drug seeking” morally relevant?

6. Are any of the following circumstances morally germane: the patient’s homelessness, his joblessness, his apparently deliberate non-rehabilitation, his absence of visitors?

7. What biases do members of the clinical staff bring to this case? Are the biases justified? How do such biases affect the goals of care and proper pain management for this patient?

8. As a clinician, patient advocate, or member of the ethics committee, what policies or procedures do you recommend to ensure that this patient and others will not receive unequal treatment because of these biases?

Diane Deese, BA, EMT, is the director of Community Affairs at VITAS Innovative Hospice Care, Chicago, Illinois.

Pat Tadel, MSN, RN, CHPN, a thanatologist, is director of academic programs at VITAS Innovative Hospice Care and a senior ethics fellow, MacLean Center, University of Chicago.

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