Case Bank


  • Family Disagreement

    Ms T was found unresponsive at home in April 2014. Paramedics were called and CPR was performed. She was intubated in the Emergency Department. Ventricular fibrillation was indicated as the cause of the cardiorespiratory collapse. CT brain scan showed a brain tumour — likely a meningioma. Ms T has been unconscious since her collapse due to hypoxic encephalopathy. She also has a complete heart block, which required the placement of a temporary pacemaker. She is not brain dead because she failed one of the criteria for brain death. However, she is ventilator dependent. Ms T’s poor prognosis was communicated to the family and an end of life discussion held. They are unable to agree on what to do next. Madam T’s husband and children think life support should be withdrawn, following the advice from the medical team that treatment will only prolong the dying process. Ms T’s siblings however wish […]

  • Risk communication of surgery

    A patient, Ms B, aged 50, saw surgeon Dr E for a 2 cm nodule in the head of the pancreas found on routine ultrasound screening. After doing blood tests and MRI scan, the nature of the pancreatic nodule remained unclear and Dr E told Ms B so. Ms B was told that the tests were inconclusive and ambiguous. She was given the alternatives of either waiting-and-watching, with repeated scans over months to see if the nodule changed, or go for surgery to remove the mass. The usual information about surgery, such as bleeding, infection, wound breakdown, deep vein thrombosis, heart attack and stroke were all disclosed to Ms B. She chose the surgery. The mass turned out to be entirely benign. However, there were complications of surgery leading to prolonged ICU stay and hospitalization and her hospital bill, which she had to pay for, was very high. Ms B […]

  • Surgery on a Relative

    Doctor Zoe is the most experienced surgeon in a surgical subspecialty. Her husband has developed an illness and is found to require a difficult surgery in Dr Zoe’s specialty. The most suitable person to perform the needed surgery is Dr Zoe herself. Dr Zoe decides that she will be the surgeon rather than risk her husband at the hands of a less experienced colleague and seeks advice from the Hospital Ethics Committee on the ethical appropriateness of the proposed plan. Questions for Discussion Is there a conflict of interest and if so what is it and how could the Ethics Committee help to resolve the dilemma? What ethical principles are at risk of being violated?

  • Team management of errors

    Dr A is the consultant in charge of a team of junior doctors including a registrar, a medical officer and a houseman. At the outset, Dr A tells the team what is required of them and the standards he expects from all his team members. In the course of managing patients, the registrar Dr C tells Dr A that medical officer B seems unsure of himself and has made a number of minor errors in documentation, ordering tests and medicines. Then one day medical officer Dr B receives blood for transfusion into a patient. He fails to cross check the identification information between the blood and the patient and gives it to the wrong patient. The patient has an acute transfusion reaction and becomes severely ill. Another time, the same Dr B injects an antibiotic into a patient without first checking the patient’s drug allergy history and the patient goes […]

  • Terminal Discharge

    Mr N was diagnosed with cancer last year and treated with chemotherapy. He was diagnosed with brain metastasis on this admission. Mr N spoke to several nurses and said he wanted to stay in hospital. He did not want to burden his relatives at home because they were busy working. When the nurses asked him if he had shared his views with his relatives he said he found this difficult. His condition deteriorated rapidly over the next few days and he lost capacity to make his own healthcare decisions. Mr N’s wife told the doctors that Mr N wished to die at home and observe Buddhist rites upon death. These rites, which include 8 hours of chanting and an 8 hour no-touch rule, would be difficult to undertake in a hospital. N’s brother and wife offered to be his caregivers. The medical social worker advised that the family were not […]

  • Unaffordable Care

    The Nice United Hospital has in the previous year incurred bed debts totalling 3 million dollars arising from treatment provided to inadequately insured foreigners, the majority of whom were emergency admissions. Consultants have been reminded to consider carefully the patient’s ability to pay the fees before embarking on especially for non-emergency treatment and if deemed unable to pay, patients are to be directed back to their country as soon as travel becomes safe for the patient. Tourist Mr. Nikon from a nearby developing country presents to the Emergency Department with clinical features and ECG findings of a myocardial infarction; he is admitted under Dr Compassion to the Coronary Care Unit and is stable and not hypotensive. The standard protocol is for an angiogram followed if needed by an angioplasty with the understanding that this may precipitate for an emergency coronary bypass surgery. Mr. Nikon cannot afford the estimated bill and […]