To Your Good Health: Consultation, treatment hinges on wishes of patient, not family
BY KEITH ROACH, M.D.
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 life-and-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.