A 70-year-old woman is brought to the office by a friend who became concerned at finding her very weak and pale during a recent visit. The friend had not seen the patient in more than 6 months and was shocked at her condition. The patient says, "I feel very tired and have to sit down a lot to rest." She has had these symptoms for the past 10 months, but they are becoming progressively worse. She was diagnosed with primary myelofibrosis 2 years ago. The patient was not offered bone marrow transplantation due to her age; instead, she has received blood transfusions on more than 10 occasions, as well as erythropoietin and androgens, which have yielded poor results. She has no other medical problems and takes no other medication. The patient is widowed and lives with her son, who cares for her. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 110/min, and respirations are 20/min. She appears pale and undernourished, with significant muscular wasting. Auscultation reveals tachycardia. Hepatosplenomegaly is present. Laboratory results are as follows: Three months ago, when her hemoglobin level was 8.0 g/dL and her hematocrit was 24%, the patient stated that she did not want any more blood transfusions or treatment. She understands that her condition is worsening but has not changed her mind, and continues to refuse any type of therapy. Which of the following is the most appropriate course of action?

Question

A 70-year-old woman is brought to the office by a friend who became concerned at finding her very weak and pale during a recent visit.  The friend had not seen the patient in more than 6 months and was shocked at her condition.  The patient says, "I feel very tired and have to sit down a lot to rest."  She has had these symptoms for the past 10 months, but they are becoming progressively worse.  She was diagnosed with primary myelofibrosis 2 years ago.  The patient was not offered bone marrow transplantation due to her age; instead, she has received blood transfusions on more than 10 occasions, as well as erythropoietin and androgens, which have yielded poor results.  She has no other medical problems and takes no other medication.  The patient is widowed and lives with her son, who cares for her.  Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 110/min, and respirations are 20/min.  She appears pale and undernourished, with significant muscular wasting.  Auscultation reveals tachycardia.  Hepatosplenomegaly is present.  Laboratory results are as follows:  Three months ago, when her hemoglobin level was 8.0 g/dL and her hematocrit was 24%, the patient stated that she did not want any more blood transfusions or treatment.  She understands that her condition is worsening but has not changed her mind, and continues to refuse any type of therapy.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: The only effective medical treatment for primary myelofibrosis is allogenic hematopoietic cell transplantation. Unfortunately, only patients age <60 can be considered as candidates. The rest are treated with palliative measures only. This patient has a number of factors associated with poor prognosis: significant weight loss; hemoglobin level <10 g/dL, leukopenia (white blood cells <4,000 /mm³) and platelet count <150,000/mm³. The principle of autonomy includes a patient's right to refuse treatment. Although it may be difficult for the physician to forgo treatment that could improve this patient's symptoms, her decision must be respected. She should be allowed to go home with arrangements for palliative care if she chooses. Unless the court rules that this terminally ill patient is incompetent, she can continue to exercise her right to determine what she thinks is best. (Choices B and C) This patient has clearly stated her decision and has not requested assistance from her friend or son. Involving them is not indicated and may make the patient feel undermined. (Choice D) Patients should be referred to a psychiatrist if there is concern that an underlying psychiatric illness (eg, psychosis, depression) is impairing the patient's decision-making capacity and/or requires treatment. This patient shows no evidence of psychiatric illness or lack of decision-making capacity. (Choice E) This patient has refused any type of therapy for her condition. Sending her to the emergency department against her wishes violates her autonomy. Educational objective: Patients with untreatable diseases and a poor quality of life, and who have already tried different therapies, may sometimes refuse to accept any kind of treatment. The principle of autonomy includes a patient's right to refuse treatment, and the physician must respect the patient's decision.

A 70-Year-Old Woman Is Brought to the Office by a Friend