Introduction: patient at the centre of this study I
A Case-based discussion is an organized interview between a healthcare professional and a patient in a clinical setting to provide structured feedback on a specific area of clinical practice. They are seen to have high validity and can be used as a teaching aid and assessment tool. Case-based discussions can be beneficial for the future of learning and training in a clinical environment by providing useful feedback for trainees about specific cases and their own clinical knowledge.
The patient at the centre of this study I will call Mr Bernard, this is not his real name.
Mr Bernard is 65 years old and was born and raised in England as an only child and currently lives in a care home in the South East of England. Previously he worked as a waiter just after he graduated until he was 25 and then took part in some training to become a boat chef, as he realized cooking was a passion for him. This then became his occupation until the age of 43. At around the age of 28, Mr Bernard got married to his wife and they had one son at around the same time. During one of his boat trips when he was 43 he had a traumatizing accident as he fell down a flight of stairs on the boat and ended up getting brain damage from the fall. This meant he was hospitalized immediately. Following the accident, his memory had significantly decreased and gradually worsened. Unfortunately, Mr Bernard’s wife passed away around 6 years ago which also took a great toll on his health as he became alcoholic. His son believes his actions have become more aggressive and has developed quite a violent nature due to the death of his wife and his increased intake of alcohol. His only son currently lives in Australia as he works there and has a family of his own. Even though his son does live so far away he does come and see Mr Bernard every 2 months for a few days at a time. He is known to show self-neglecting behaviour due to his mental state and doesn’t like to be involved in many social gatherings and does not associate much with others. Due to his alcohol addiction, he has also developed Korsakoff’s syndrome (alcohol-related dementia) over the past 6 years, which is due to drinking alcohol excessively for the past few years. This is has caused his short-term memory to worsen and has slowed his ability to pay attention and think logically.
Overview of the Case:
Last year Mr Bernard was diagnosed with the liver disease as he began dramatically losing weight and his ankles started to become swollen. After multiple tests were carried out, it was found out that due to his overindulgence in alcohol, Mr Bernard developed cirrhosis. The liver started deteriorating quickly to the point that now he is in end-stage liver disease or liver failure and he is very desperate and in need of a transplant. In the state that he is in his son is adamant that he should be put on the list for the transplant immediately, however, doctors are not too sure whether the liver transplant will be beneficial for Mr Bernard. They are not too keen that he will be able to cope with the transplant as it means he would have to stop drinking alcohol which will be a huge struggle for him due to his mental state and behaviour. In the past, he has shown self-neglecting behaviour and this may cause him to struggle when controlling his alcohol intake. The treatment agreement also states that “the patient may be asked to sign an agreement that they will not drink alcohol post-transplant and will comply with follow-up if the team feel that will promote long-term abstinence” (Liver selection Policy, 2008, p.5.). Also prior to the transplant surgery, he must be alcohol-free for around six months to aid his liver to recover from damage slowly, however, this is all down to his behaviour patterns and his own choice. Mr Bernard does have the capacity to make the decision on whether he wants the transplant but he himself doesn’t believe he will be able to refrain from drinking alcohol for months and may get alcohol relapse which is concerning for both his son and the doctor, but he does wish to receive a new liver. The doctors are also anxious that the list for liver transplants is ordered according to priority and are unconfident that Mr Bernard will be able to receive a transplant in time as the waiting lists can be around 135 days. This case is controversial in the sense that recipients like Mr Bernard did cause the illness on himself as he did not choose to drink alcohol in moderation, therefore leading to the liver failure, which can be unfair to those who require the transplant due to other health conditions. The UK regulations also state that “it is expected that you have at least a 50% chance of surviving for at least five years after the transplant with an acceptable quality of life” (NHS Liver Transplant, 2015). In Mr Bernard’s case, this is possible but there is a chance that his body may not accept the new liver and his immune system is quite weak which can be fatal.
From the overview of that case, it is clear that Mr Bernard is desperate for the liver transplant, however, there are a few complications such as the fact that doctors are unsure that replacing his failing liver will cause a change in his attitudes towards alcohol and drinking excessively. Even though doctors are not sure, Mr Bernard’s son is adamant that his father will change his ways, and this can be a road to recovery for him. His son believes he has every right to be put on the waiting list for the transplant like others and shouldn’t be treated differently due to his current state as he has seen others in similar conditions who have been treated the same. Since there are conflicting views about whether Mr Bernard should be placed on the waiting list, it has put a lot of stress on Mr Bernard’s son, on his doctor and on Mr Bernard himself too, as he thinks the liver transplant is the only option. Additionally, after receiving the liver transplant it can be quite a slow process of recovery and the immunosuppressants that he will have to take do have quite a few side effects which can be a lot to deal with especially the fact that Mr Bernard does also suffer from Korsakoff’s syndrome and has had head trauma. One of the side effects of the immunosuppressants, calcineurin inhibitors, is that he will get headaches and can have increased risk of infections which means he will have to be monitored constantly due to his current poor immune system. As well as this, due to the other immunosuppressant, corticosteroids, Mr Bernard’s mental state can change negatively which can be very dangerous for his health and can worsen his current aggressive behaviour as the medication can heighten his frequent mood swings and cause him to have suicidal thoughts. If Mr Bernard does receive the transplant and decided to start drinking again this can also be very toxic as the drug acetaminophen can mix with alcohol and damage the liver further. As his previous head trauma did not affect his communication skills or ability to make decisions, Mr Bernard will be able to decide whether he wants to undergo the transplant however it is the healthcare professionals decision on whether they believe he is a suitable to be on the waiting list.
Even though Mr Bernard does suffer from Korsakoff’s syndrome and short-term memory loss, as the patient it is also his choice whether he wants to receive the transplant. He shouldn’t be discriminated due to his illnesses as the NHS “have a duty to take reasonable and appropriate measures to uphold the human rights of those who are vulnerable due to ill health or disability” (Law and Professional Issues in Nursing, 2017, p.68). As the patient in this situation, Mr Bernard would be feeling anxious and desperate since, without this transplant, his life expectancy will rapidly decrease, but he is also unsure whether the liver transplant will be successful for him. It can also be disheartening to hear the doctors say they are not confident that he will have a rapid recovery after the transplant and can lead him to feel nervous that the surgery may lead to other complications in health by bringing out other issues. This can cause him to be feeling stressed or overwhelmed by the thought of the transplant surgery not going successfully. As well as this, Mr Bernard may feel worried that he will not be able to maintain good health post-surgery by refraining from drinking alcohol as his addiction is very serious. He may feel as though there may be someone else that may benefit more from the transplant than him due to his age and current health. He could also feel pressured to receive the transplant, as his son has so much confidence that he will be able to improve his lifestyle after the surgery and he may not have that much faith in himself. On the other hand, Mr Bernard may feel as though having the transplant may better his attitudes towards his health and lifestyle as it can improve his self-neglecting behaviour as he will be able to understand how much he had to go through to start over with a new healthy liver. He may also feel that the change in lifestyle could improve his aggressive/ unpredictable behaviour as he may be more appreciative after recovering from the surgery.
To conclude, Mr Bernard was diagnosed with cirrhosis last year and currently is in desperate need of a liver transplant due to the extent of damage done to his liver by excessively drinking alcohol over the past 6 years. Doctors haven’t made a final decision on whether he is suitable to be placed on the waiting list for the transplant due to his existing mental health from a previous head trauma, weak immune system and alcohol-related dementia. But his son is demanding that he be put on the waiting list as he believes this surgery is life changing and can change Mr Bernard’s lifestyle for the better. Doctors are unsure that Mr Bernard will be able to control his alcohol addiction and are concerned that the effects of the medication from the transplant could heighten his unpredictable behaviour and worsen his mental health. However, they know that without the transplant his lifespan will shorten to only a few months and his son believes this transplant could cause a change in his lifestyle completely, for the better, if he makes sure to maintain a healthy routine. It can benefit his health in multiple ways and give him a new outlook on life. The doctors also can not disregard the laws and not allow him to receive a transplant by discriminating him due to his disability and multiple health conditions. If Mr Bernard does go through with the liver transplant there are benefits and a few complications, such as the immunosuppressants having unpleasant side effects like increased risk of infection and issues developing with the kidney but these will all be explained before the procedure. He will also have to maintain a healthy, balanced diet and stop consuming alcohol, being the hardest issue for him as alcohol relapse is common in recipients that were previous alcoholics. On the other hand, if Mr Bernard chooses to not go through with the surgery the length of his lifespan will shorten, and his quality of life will rapidly decrease.