Module 2 – Respecting Patient Rights
Ethics Case 2.2
Pancreatic Cancer & Questionable Capacity
Mrs. Spade, a 48-year-old accountant, was referred to Dr. Eze by her oncologist after being diagnosed with localized pancreatic cancer. During the initial surgical consultation, Dr. Eze explains that being “localized” means that it hasn’t spread outside of the panaceas yet, and that she has a 44% five-year survival rate if she quickly undergoes surgery followed by intensive chemotherapy. However, if her cancer spreads to her lymph nodes and becomes “regional,” the five-year survival rate drops down to 16%. Mrs. Spade looks out the window and sighs, saying “I know how serious it is. I watched my aunt die from pancreatic cancer seven years ago. They did everything they could, but she just got worse and worse until she died.” Mrs. Spade also mentions how physically and emotionally tired she has felt over the past three years starting around the time her husband died suddenly and tragically; when out jogging one evening, he was run over in a crosswalk by a distracted driver. She says that it has been hard to motivate herself to get up some days, and she doesn’t do much apart from going to work and visiting her mother.
When Dr. Eze asks about her support system, Mrs. Spade tells him that she tries to visit her elderly mother’s nursing home at least once a week. “I’m all she has left, but I feel like I’m failing her. Some weeks I don’t get there at all. I’m supposed to be present for her, but most days I feel like I’m hardly present for myself.” She also says she has a few friends in the area but hasn’t been good about keeping in touch with them since her husband died. Mrs. Spade’s medical records indicate that she’s lost 25 pounds over the past two years and has had several episodes of severe fatigue requiring emergency room visits.
Dr. Eze explains that the recommended surgery is called a Whipple procedure which would remove the head of her pancreas, part of her small intestine, her gall bladder, and part of her bile duct. Dr. Eze explains the surgical risks and says that while it’s a complex procedure, the 44% five-year survival rate is encouraging and strongly recommends that she undergo the Whipple procedure followed by chemotherapy. Mrs. Spade listens carefully and asks a few questions about the risks and treatment protocols. She also mentions that she has recently made plans to travel to Rome the following year and asks if the treatments will likely be completed by then. At the end of the consultation, as Mrs. Spade agrees with the treatment plan Dr. Eze has laid out while saying that she has a lot to think about and will be glad when all this is behind her.
At their follow-up consultation a week later, Mrs. Spade appears withdrawn. “I’ve decided against the surgery and chemotherapy,” she says plainly. When Dr. Eze asks her to explain her change of mind, Mrs. Spade responds that “I’m concerned about how hard the surgery and chemotherapy will be on my body. I’m already so exhausted, it’s hard to imagine suffering through the treatments and recovery, too. Only four-out-of-ten patients with my condition even make it to five years, and even if the treatments do help, what do I really have left in my life, anyway?” Dr. Eze suspects that Mrs. Spade is thinking about what she saw her aunt go through, as well as the immense grief she’s been dealing with since losing her husband.
Those suspicions are confirmed when Mrs. Spade adds “I told you my aunt went through this. Hers was localized too, and even with the aggressive treatments, she still died after eight months. Those months were filled with a hard recovery from surgery and debilitating side effects from the chemotherapy. That’s not living, it’s just suffering before dying.” Dr. Eze again reminds her that the five-year survival rate is encouraging for localized cancer when treated quickly, and expresses concern about her mental state, asking if she’s ever sought treatment for depression. He suggests that it might change her thinking about how valuable the treatments could be for her.
Mrs. Spade quickly becomes defensive, saying “I’m just being realistic. The treatments aren’t worth it to me. I’ve thought a lot about my life over the past week, and there just isn’t any reason to keep going, especially since my husband died. Honestly, I’d rather be with my husband than go through all that. I’m okay with things ending here. I’ve lived my life and I’m tired of suffering. I just want to be with my husband. I miss him all the time.”
Concerned about Mrs. Spade’s mental state and her decision, Dr. Eze contacts her primary care physician, Dr. Martinez. “She’s been my patient for eight years,” Dr. Martinez confirms. “She’s always been incredibly stubborn, but she’s also been open to taking care of her health. Sure, there were times when she seemed a little withdrawn, but nothing ever jumped out at me. But you’re right that she’s seemed a bit different the past few years. Perhaps I should have screened Mrs. Spade more carefully for depression.”
Given this conversation, Dr. Eze refers Mrs. Spade to Dr. Henry, a psychiatrist. She agrees to meet with Dr. Henry who evaluates her and diagnoses her as experiencing a depressive episode and ongoing complicated grief. This is likely triggered by the cumulative stress of her illness, her mother’s needs, and the unexpected death of her husband. Dr. Henry recommends antidepressants and therapy. However, Mrs. Spade refuses to pick up the antidepressant prescription and fails to show up for the therapy appointment. When Dr. Henry calls her, she tells him “I’m not going through with it so just leave me alone. I don’t have the energy for this.”
When Dr. Henry relays this to Dr. Eze, they are both concerned that her choice seems inconsistent with previous willingness to manage her health concerns and accept treatments, suspecting her refusal might be influenced by her grief and depression. Her health will continue to worsen with each passing week, and Dr. Eze questions whether Mrs. Spade has the capacity to refuse the potentially life-saving treatments. Conflicted on what to do, Dr. Eze contacts your ethics committee for assistance with a capacity assessment and a recommendation on how to proceed.
