Case studies

Case Study 1: Cultural relevance in end-of-life care (Adapted from Coolen, 2012)

Mr Wu is a 70-year-old Chinese man who lives with his wife of 40 years. Mr Wu was diagnosed with lung cancer two years ago, but is now failing rapidly. He is very weak. He can no longer eat due to increased difficulty swallowing and breathing. He does not complain of pain, but his wife says that his back hurts. His two sons live nearby. His daughter moved in recently to help her mother care for him.

Mr Wu’s GP wants to make a referral to hospice services. Mr Wu says the doctor must talk with his sons first. In a telephone conversation with the sons, the sons agree to hospice services. However, the older son does not want his father to know he is dying and does not want the word “death” to be used when talking with his father. The son tells the doctor, “We do not tell our father that he is dying. Telling him is harmful, causing undue emotional burden for him. We are responsible for protecting him from harm”. Mr Wu does not take part in the conversation nor does he make his wishes known. Mr Wu does not have an advance directive.

A week later, Mr Wu is admitted to the hospital with aspiration pneumonia. He is barely conscious, febrile, and his breathing is slow and irregular. The family continues to encourage Mr Wu to eat. The older son is considering requesting treatment and the use of a feeding tube and antibiotics. The wife and older son refuse to discuss or participate in the conversation regarding end-of-life care with the nurse or physician.

However, the younger son acknowledges that his father is dying. After much discussion and tension within the family, the family agrees to allow Mr Wu to die peacefully with comfort measures only. Mr Wu dies within 24 hours of admission.

Case Study 2: Mr Singh (adapted from Hasan & Periyakoil, 2010, p.18)

Mr Singh, a 76-year-old Punjabi male, is brought to an outpatient clinic for an evaluation of gait unsteadiness. He has been diagnosed with renal cancer with metastases to the lungs. His wife died five years ago and he then moved to New Zealand as all his children are settled here. Mr Singh is a farmer from Punjab. He does not speak English.

A left hemiparesis is found during the examination and the doctor wants to get a head CT to rule out brain metastases. His eldest son, who is the interpreter, accompanies Mr Singh and says that he is the primary decision maker for his father who confirms this statement.

The son takes the doctor aside and requests that she should not tell the client about suspicions of brain metastases. He agrees with getting the head CT and obtaining a radiation oncology and oncology consult, but requests that all these doctors not mention the word “cancer in the brain”. They can discuss treatment without mentioning the word “cancer”. He thinks that if his father knows about the cancer in the brain, he will lose the will to live.

The son still believes that his father will be cured of cancer. In addition to the medical treatment he is receiving, the family are also consulting with a spiritual healer who has assured them that the cancer will be cured in six months.

The CT scan of the head shows a large brain mass on the right side causing cerebral oedema and midline shift. The client is started on oral corticosteroids and radiation therapy. The spiritual healer has given Mr Singh and his son butter that is blessed with holy words, and they apply it to his head, lungs and abdomen. Mr Singh develops dermatitis on the scalp, and is told by the radiation oncologist not to use this “hair oil”. The client stops eating and drinking and becomes very weak and is admitted to hospital.

Multiple attempts to address treatment options with the son have been unsuccessful. The son wishes his father to be coded for resuscitation. He believes that his father will be cured and that it is in God’s hands. He gets angry with the doctors and thinks that they just want to get rid of his father because they want to save money.

The palliative care team in the hospital is consulted and they use an interpreter not related to the client. The interview is conducted at a time when family are not present. During the interview, Mr Singh starts to cry, and says multiple times that he wishes he were dead. He says he is so ashamed of the fact that he can’t walk and that his daughter-in-law has to help him get in and out of bed. He is even more ashamed about the faecal and urinary incontinence and that his daughter-in-law has to see him naked and clean him. He says nothing can be worse than this.

He does not want to go to the spiritual healer but he knows that his son still thinks that he can be cured and wants to go on. He does not want to share his thoughts with his family, as he does not want them to think of him as a weak person. He still defers all decisions regarding his health care to his oldest son, but wishes that the son would give up and face the reality that he is dying and let him die in peace.