Truth-telling, code status and an insulin medication error
A 68-year-old Omani woman with end-stage kidney disease on thrice-weekly hemodialysis is admitted with weight loss and a new colonic stricture. Biopsy confirms adenocarcinoma. She is alert, oriented, and asks repeatedly, 'What did the tests show?' Her eldest son, who holds the family's decision-making role, takes the team aside and says, 'Do not tell her. It will kill her hope. And if her heart stops, do everything.' She has no written advance directive. Later that evening, a nurse administers 10 units of rapid-acting insulin instead of the prescribed 4 units because the order was transcribed incorrectly; the patient becomes sweaty and confused, and a capillary glucose is 2.8 mmol/L. She is treated with IV dextrose and recovers. The resident must speak with the son, the patient, and the team.
1. The son insists that his mother must not be told the diagnosis. How do you respond, and how do you assess whether she has capacity?
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Start from the patient's right to information, then assess capacity specifically for this decision.
Capacity assessment requires that she can understand the relevant information, appreciate how it applies to her, reason with it, and communicate a choice. She is alert and asking about results, so assume capacity unless there is evidence otherwise. Speak with her alone, with an interpreter if needed, and explore how much she wants to know. Do not lie or give misleading reassurance.
With the son, acknowledge his distress and the cultural importance of family involvement. Explain that adults with capacity decide for themselves whether to receive information; family can be present and can help, but they cannot veto disclosure unless the patient has clearly asked not to be told. If the patient says, 'Do not tell me,' that wish should be respected, and the son can be designated to receive information with her consent. Document the conversation.
If she lacks capacity after formal assessment, act in her best interests and involve the family, but still give information at a pace she can tolerate. In Oman, family-centred practice is important, but it does not override a capable adult's autonomy.
Reasoning: The ethical conflict is between beneficence as the son sees it and respect for the patient's autonomy. Capacity assessment resolves who decides; it does not allow the team to deceive a capable patient.
2. She has capacity and says she wants 'everything done' if her heart stops, but the team thinks CPR would be futile. How do you handle the code status discussion and the son's demand for full resuscitation?
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Clarify what she means by 'everything' before writing a code status.
Explain CPR, intubation, intensive care and dialysis in plain language, including the likely outcomes with metastatic cancer and end-stage kidney disease. Ask what matters to her: survival, comfort, being at home, or not being a burden. A capable patient's informed choice should be respected, but clinicians are not obliged to provide treatments that are medically inappropriate. If CPR would be futile, say so clearly and compassionately, and offer alternatives such as a DNAR order with full comfort care, symptom control and palliative input.
Do not write a DNAR unilaterally without a proper process. Hold a family meeting with the son, the patient (if she agrees), the treating team and palliative care. Explore why the son demands full resuscitation; it may reflect guilt, fear of losing her, or a belief that withholding CPR is abandoning her. Reassure him that comfort care is active care.
If conflict persists, follow local policy and involve the ethics committee or a senior clinician. Document the discussion, the patient's expressed wishes, the medical opinion and the agreed plan.
Reasoning: Code status is a medical decision made with the patient, not a family vote. The goal is to align treatment with the patient's values while avoiding non-beneficial interventions.
3. How do you disclose the insulin error to the patient and family, and what system changes would you propose?
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Disclose promptly, apologize, explain and document.
- Speak to the patient first, in person, with a senior clinician if possible. Explain that she received more insulin than prescribed, that this caused low blood glucose and confusion, and that she was treated with dextrose. Apologize for the harm. Answer her questions and tell her what will be done to prevent recurrence. With her consent, include her son.
- Monitor her glucose closely and document the incident in the medical record. Do not blame the nurse individually; the transcription error is a system problem.
- Report the event through the hospital incident-reporting system and trigger a root-cause analysis. Review the prescription, transcription and administration process.
- Propose system changes: electronic prescribing with default insulin doses, independent double-check for insulin, separation of 4-unit and 10-unit vials, standard order sets, barcode scanning, staff education, and audit of insulin errors.
- Follow up with the patient and family after the disclosure and check whether they need further explanation or support.
Reasoning: Duty of candour requires honest disclosure of harmful errors. A blame-oriented response discourages reporting; a systems response is more likely to prevent the next error.