Counselling Dilemma: A Sensitive Client Request
You have a long-term client who is suffering from liver failure. Trevor is 45 years of age and was diagnosed with this condition approximately 3 years ago. His state of health is rapidly deteriorating and he has recently been hospitalised, awaiting a transplant. Trevor has a rare blood type and all attempts to acquire a compatible organ for him have been unsuccessful. The medical team is urging Trevor to move on to a more intensive life support system while he awaits a transplant.
You have worked with Trevor regarding his deteriorating health and related issues for over 18 months. Trevor has accepted his declining health and has worked through his feelings about death. The possibility of a transplant was Trevor’s last hope, however. He is now faced with the prospect of spending his final days in intensive care and has been weighing his options about refusing treatment or waiting for the transplant.
During your last counselling session with Trevor and his wife, Trevor decided that he wants to refuse intensive treatment and to return to the comfort of home. He asked if you would talk with the medical team and inform them of his decision.
Would you agree to Trevor’s request? What would your values be in this situation? How might they affect your actions in this case?
I do not have any issues with regards to my client?s choices in this scenario as my own values indicate respect for the client?s wishes. I would agree to support him in his decision to discontinue active treatment in order to increase his quality of life.
There are some issues to consider in supporting the client. These are:
– The client?s acceptance of death
– Anticipatory grief
– The impact of his decision on his wife and children and other family and friends and how they are coping
– Assist him in discussing his decision with his doctor
– Referral to support services
Firstly I would work with my client in relation to his decision and his acceptance of death. Are there any issues that have remained unresolved for him? Often clients will grieve about unfulfilled goals and dreams (i.e. seeing children grow up, graduate and marry, being a grandparent, etc).
Does he have any fears? Some clients may fear being in pain or may want to know what happens when they die. Often expressing these feelings and fears is helpful for the client. I would answer any questions honestly from my experience. In addition, I would assist the client to talk to his doctor (usually his GP) about any medical issues pertaining to his decision. The client may wish to discuss his spiritual concerns with me. I am comfortable working with him, respecting his own beliefs and, if he requested, referring him to someone of his own faith for spiritual support.
In addition to working with my client?s issues, I would discuss with him how his family (particularly his wife) are coping with his decision. This is important as his close family will form the backbone of his support out of hospital. In some cases the client?s family have difficulty accepting a decision to pull back from intensive medical treatment. Are they okay with the fact that he may die? Are they angry about his decision? Are they in denial? The family is likely to be experiencing anticipatory grief towards his possible death and their reactions to his decisions may be quite different to his own. Each member of a family can react differently being in different stages of the grief process.
I would offer to work with his family to aid them in their individual experiences of grief at this time. I would also assist my client to prepare for the type of reactions that he may experience from close family or friends.
My actions for this client would include a discussion with his doctor or medical team regarding his choice. Of course I would obtain the client?s written consent to do this. I would request that the medical staff liase further with my client about his options and I would support my client during this process. My client may also decide to negotiate an Advanced Health Directive, in consultation with his family and GP. An Advanced Health Directive would outline my client?s wishes for future health care, should he lose the capacity to make his own decisions.
It would be helpful to link my client and his family into a Palliative Care Service in their area. Palliative Care Services provide support to patients who chose to have medical treatment at home. They offer a range of services including nursing care, medical aides, counselling, and visiting support volunteers.
My service to this client and his family may also include follow-up counselling and support after the death of the client. At this point in time, family members have often shared much of themselves with the counsellor and find continuing comfort in this relationship as they cope with their loved one?s death.
I would agree to talk with the medical team on behalf of Trevor, or with Trevor and his wife present, depending upon their wishes in this case.
I am clear about my own values, as I believe that each person has a right to choose to die when confronted with a terminal illness. I would be likely to make a similar choice to Trevor if I was faced with the same situation. Trevor?s choice is therefore in line with my own values.
I have supported individuals in this type of situation in the past and have worked to meet their needs and support their requests. I would respect Trevor?s decision to discontinue treatment at hospital and assist him in whatever way I could.
What would Ronda or Aileen do in working with a situation where one or more members of Trevor’s family were strongly opposed to ( to the point where they felt they must actively intervene) his decision to discontinue active treatment?
In the situation where one or more members of Trevor’s family were strongly opposed to his decision to discontinue active treatment, to the point where they felt they must actively intervene, the following points could be considered:
There is no evidence in the case summary that Trevor’s cognitive capacity is impaired or has declined in a way that has resulted in him losing the capacity to make his own rational and legal decisions about his medical treatment. There is also no information in the case summary that suggests that his family have active enduring powers or a guardianship order in place that could give them any capacity to make decisions about medical treatment for Trevor. His family therefore could be limited in the kind of interventions they could make that could actually legally compell Trevor to get the treatment they want him to. Having said this, it could be important to check the legislation in each state to determine the conditions under which family members can act on behalf of persons to receive medical treatement.
It could be helpful to explore with Trevor how his family’s wishes are effecting him, so that ways of supporting him can be developed. With Trevor’s knowledge and consent, it could also be helpful to hold a family meeting with Trevor, his relatives and senior member of the medical team, so that the issue could be discussed in a way that is sensitive to the family’s grief, while also emphasising Trevor’s right to self-determination.
In Trevors case I as his counsellor would do what I could to honor his wishes, but only in so doing that he and his wife have already discussed this
sensitive issue with other concerned family members. It’s not easy to accept what your loved ones final decision may be. Nobody likes to be reminded that there actually is and end to human life and no matter what our own personal, religious or ethical reasons are. The final decision should be that person’s.
This article actually makes me think of what my own values would be if it were me I know that I would want to have the final say on my behalf.
I think it would be desirable to respect Trevor’s wishes. If he is kept in the hospital with intensive care he would not have mental happiness. He would be angry wih everyone for not granting his request.
But I would like to first discuss with his family members and get their views . If they are in agreement with Trevor there is no issue but if some members oppose I will try to put up pros and cons of both situations and get thm to see reality. The importance of continuing treatment at home will be emphasised to ll family members. Counselling too to be continued. The effort to find a transplant to be expedited with assistance of media etc.
Then along with the family members I would discuss with the medical team.
It is not my role to inform medical staff of Trevor’s decision. It is something that he must do himself. It is not the issue (refusal of treatment) but the need for Trevor to be fully accountable for his decision.
I would discuss with Trevor and his wife how they can approach his doctor whom I am assuming he has been seeing for some time now and has built up a relationship. There is no need to discuss with the whole Medical team.
I would also discuss how to inform other family members of his decision.
It has nothing to do with my own values whatsoever – it can not.