This case commentary is about Mr Subramanian* who is suspected of having dengue. It covers a variety of aspects such as his background and history, the biological aspects, the ethical and legal concern, the sociological perspective and also his way of life. His view on having the condition and my own standpoint will also be discussed.
Background and History
Mr Subramaniam* is a 77-year-old Indian man and a retired insurance sales agent. He is married and has only one son who is currently abroad. He came to the clinic as he has been having fever, cough, dizziness and often feel nauseated for a week. He has been taking medication to reduce the symptoms. The doctor suspected it is dengue and has told him to do a blood test.
Concurrently, Mr Subramanian* has hypertension and high cholesterol level which is controlled by medication. He comes to the clinic annually for his checkups. Besides, every six months, he will have his prostate examination. This is because his mother has prostate cancer and has passed away in 1992 and he has a high risk of developing the disease. On the other hand, his wife is diabetic and is taking insulin twice a day; once in the morning and another one at night.
In 2017, Mr Subramanian* has broken his hip bone and has undergone surgery and was also hospitalised. Apart from this, he has never had any other major injuries and hospitalisation. He also does not have any childhood illnesses and wasn’t sure about the status of his immunization. Mr Subramanian* is allergic to Ponstan and the nature of its response is vomiting. Apart from that, he is not allergic to any other substances.
The medication that he is taking are listed as below:
Medication
|
Frequency
|
Dosage
|
Chlorpheniramine Maleate
|
1 tablet, 2 times daily
|
4mg
|
Paracetamol
|
4 times daily
|
500mg
|
Bromhexine Hydrochloride
|
3 times daily
|
8mg
|
Mr Subramanian* does not drink alcohol and has never smoke before. He has difficulty in sleeping as, throughout the night, he will wake up a few times. According to him, his living environment is fine. He told us that none of his neighbours has dengue, however, he noticed that government health personnel has been conducting mosquito fogging operations in his area. His knowledge about dengue is very limited.
Biological Aspects
Viral fever is caused by a virus infection that leads to an increase in temperature which is out of the normal range. People who have lower immunity such as infants and the elderly are at a higher risk of getting the disease (Davis 2017). Mr Subramanian* is only suspected of having dengue fever which is a type of viral fever caused by a flavivirus. He has been coming to the clinic for the past few days to check his full blood count. The result of his platelet level that day is low which is only 102.
Dengue is transmitted by mosquitoes, primarily, Aedes mosquitoes. There are four dengue virus serotypes which are DENV-1, DENV-2, DENV-3 and DENV-4. A person who is infected will have lifelong immunity to the serotype (Gill 2017).
People who are at endemic tropical areas and have a prior infection with dengue fever virus are at a higher risk of getting the disease. The predisposing factors that affect the severity of the disease are age, pregnancy, nutritional status, ethnicity, the sequence of infection with the different dengue serotypes and virus genotype.
Dengue virus can cause dengue fever and also in more severe cases, dengue haemorrhagic fever and dengue shock syndrome. The incubation period is 3 to 7 days which is followed by symptoms such as high fever, severe headache, joint and muscle pain, skin rash, nausea, vomiting and mild bleeding (Gill 2017). However, there are many individuals with dengue who are asymptomatic. Mr Subramanian* has fever and nausea but do not have joint and muscle pain which is often associated with dengue.
There are three phases of dengue infection. Firstly, the febrile phase. Then, the critical phase and then lastly, the recovery/ reabsorption phase. Dengue infection causes viral multiplication which increases vascular permeability. This leads to plasma leakage in the extravascular compartment which causes an increase in haematocrit count. The high haematocrit count indicates dehydration. Besides, a decrease in platelet level and poor platelet function causes haemorrhagic manifestation resulting in the rash (Gubler et al. 2014).
Currently, there are no antiviral treatments to treat dengue. Treatments given are usually to provide symptomatic relief. Mr Subramanian is given panadol to reduce his fever and it can also be used to relieve pain. Apart from that, he should consume more water to replace the loss of fluid. In a patient who has severe dengue, normal 0.9% saline IV drip is given for fluid management and platelet transfusion can be done if there are any complications. The appearance of isles of white in seas of red is a sign of recovery (MaHTS 2015, pp. 13-42).
Ethical Issues
Medical paternalism
Medical paternalism in a health setting means acting in the presumed best interest of the patient, for example, providing treatments or service and making decisions for the patient without obtaining consent. The doctor-patient relationship in Malaysia is strongly based on medical paternalism. Patients do not know much about the disease and treatments that are being done (Ng et al. 2013). Mr Subramanian* will not question his doctor but always follow through what is prescribed. He feels that the doctor will know what is best for him. When asked whether he wanted to be involved in decision-making, he said he doesn’t mind leaving it entirely to the doctor as that has always been the case and the norm in Malaysia. However, I think that the lack of involvement of the patient in making the decision for their health care plan prevents an effective treatment plan to be conducted. This is because, when patients shape their own care and treatment based on their preferences, their wellbeing, be it physically or mentally and lives can be improved as they feel more in control and confident in managing their condition. There is also more satisfaction with the care that is provided (NHS England 2017). This is further demonstrated when Mr Subramanian* feels more worried and helpless about the future as he does not know what he should do next after the consultation. The reason for the lack of patient’s involvement in the medical decision is that health literacy is low in Malaysia and there are no policies that address the issue. Doctors are not obliged to involve the patient in making a medically informed decision but are only encouraged to by the Malaysian Medical Council (Ng et al. 2013).
Informed Consent
The four elements in informed consent are first, the patient must have the ability to make a decision. Secondly, before carrying out any treatment or procedure, the patient has to be given sufficient information on the procedure or treatment. For example, the benefits and risk, the options that are available, the likely result of no treatment and the success rate. Next, the patient must be able to understand the information given and lastly, he/she must be free from coercion and not under any pressure to conform to the beliefs, values and opinions of anyone, be it their family member or healthcare provider. Then, informed consent has to be taken from the patient or their proxy and a binding agreement must be done (Phipps 2018). Nevertheless, there are occasions where exceptions can be made. For instance, in emergencies when the patient is incapable and there are no surrogate present or advance wishes that are known and the patient’s life is in danger. Implied consent means the assumption a doctor has permission to conduct the examination, treatment and diagnostic test that is inferred rather than it being explicitly provided (Sutyanarayana Rao 2008). It is important to obtain consent as a patient are autonomous being. They are capable of making their own health care decision. For a blood test, a written consent does not need to be taken. A verbal consent is sufficient. However, in Mr Subramanian’s* case, verbal consent wasn’t given before he was told to do a blood test. It is common and acceptable in Malaysia that implied consent was given for general examination and routine investigation when the patient consults a doctor about his/her problems. Hence, it is understandable that Mr Subramanian* is not really bothered by the fact that consent was not taken before doing the test.
Confidentiality
A patient’s personal health information should not be disclosed instead it should be protected unless consent is given to release the data. Apart from the details that are collected from the patient, the diagnosis, conclusion and opinion the doctor has made are also covered under the professional duty of confidentiality (Malaysian Medical Council 2011). The ethical duty of maintaining medical confidentiality is asserted in not only the Hippocratic Oath but also in the various modernised version of biomedical codes and ethics. For example, in the International Code of Medical Ethics, the Declaration of Geneva, the Malaysian Medical Council Code of Professional Conduct and also in the Code of Professional Conduct for Nurses. Medical practitioner is required to maintain confidentiality even after the patient’ death. One of the significance of maintaining confidentiality is it respects the patient’s autonomy. We recognised that each patient has their own unique sense of individuality and the right to preserve privacy. It also protects a patient’s dignity and reduces the shame and vulnerability they faced on stigmatizing issues such as sexual and reproductive health and psychiatric problems if information that is provided are disclosed. It is also very important to maintain the patient’s confidentiality as this builds the trust a patient has for his/her doctor that personal information would not be dispersed further. When a patient’s confidentiality is violated, the integrity of the doctor is negatively affected. The patient would be less open to discuss a sensitive issue which could lead to an ineffective diagnosis and treatment. The patient would also be less likely to seek help or care in the future and be honest when medical history is being taken (Kassim & Ramli 2016). Mr Subramanian* said that he thinks the doctor does keep all the information he has given in private. He fully trusts the doctor and has established a good rapport with her. He doesn’t feel uncomfortable talking to his doctor as most of the questions asked are not very personal.
Legal Issues
Valid Consent
For the consent to be valid, the patient has to competent, free from external influence and has fully understood and accessed the information that is given (Ashcroft et al. 2007). Based on my case, Mr Subramanian* is a competent man as he is an adult (more than 18 years of age), of sane mind and is matured enough to be able to contemplate all the factors bearing on his treatment decision and authorize a medical treatment. However, it is not valid and can be challenged in court as the doctor uses a lot of medical jargons which makes it difficult for him to understand the diagnostic test he has done. He undergoes the test without asking a further question and just because the doctor asked him to.
Privacy and Confidentiality
The information that is acquired during the doctor-patient relationship is considered confidential and various acts laws are created to protect a patient’s right to maintain their privacy. However, in certain cases, a doctor’s duty of confidentiality can be broken. For example, when it is required by law when patient consents or for the public interest (Kassim & Ramli 2016). In the clinic, a patient might share the same consultation room with another patient due to the lack of rooms and space. Mr Subramanian*’s confidentiality will be breached as the other patient might be able to overhear the conversation they are having. Despite that, Mr Subramanian* understands the situation and do not complain but sometimes feel uncomfortable sharing more private and sensitive information. It should also be noted that in every consultation room, there is a curtain that can be drawn up when physical examination is conducted to preserve the patient’s privacy. Mr Subramanian* is suspected of having an infectious disease which is notifiable. Hence, if the result is positive, the doctor have to seek consent from the patient to disclose the information to the relevant authorities. Nevertheless, if he does not want to, it is still required by law for the doctor to notify the ministry for the good of the public.
Sociological Aspects
Political and Economical
In Malaysia, senior citizens are exempted from paying charges for outpatient treatment and their medication. However, RM5 has to be paid for inpatient treatment. Mr Subramanian* who does not have a health insurance plan rely fully on government funding and subsidy to pay for his treatment and medication. He is more than 60 years of age and can enjoy the benefits of the 10th Malaysia Health Plan to access free healthcare (Malaysia Prime Minister Department 2016). Nevertheless, Mr Subramanian* is not aware that there is an insurance plan for the elderly, however, it may be a bit pricey to sustain. He also stated that the country economy has not been improving the past few years. This leads to a cut in the budget for healthcare. He feels that it is unfair for the people as health is a very important element in a person’s life.
Cultural
Mr Subramanian* has never taken alternative medication as he does not believe in the efficacy of complementary medicine. He knows that insufficient scientific research has been done to prove their benefits. Apart from that, he heard about the experiences of his friends who did not get better after taking Chinese medication.
Social
Currently, Mr Subramanian* is living only with his wife who has diabetes which causes glaucoma. He has to take up the burden of taking care of his wife after the operation that is done. Due to old age, he doesn’t drive and has to take the taxi to the clinic every month for his medication. Though his son is living overseas and only comes home once a year, Mr Subramanian* knows that he will always be ready and available to take care of the both of them if need be. However, Mr Subramanian doesn’t want to trouble his son as he feels that his son has his own life and responsibility to take care of his family. His son does provide financial support and gave them allowance every month. The money and his savings are enough for the couple to live comfortably.
Self-care and Lifestyle
Education
Mr Subramanian* is not well-versed on the condition he is having. He only knows that it is transmitted through Aedes mosquito. This causes him to worry and be anxious as he does not know about the treatments that are available for the disease.
Stress-management
Ever since Mr Subramanian* stop working, he does not experience much stress. However, he is worried about his and his wife’s health. Watching the television can help him relaxed and he enjoys it.
Spirituality
Mr Subramanian* is a practising Hindu. He is also a vegetarian and goes to the temple often for prayers. When he is troubled, Mr Subramanian* will meditate and pray as it gives him a sense of relief and peace from the problems he is facing. He believes that a person’s health lies ultimately in the hands of God.
Exercise
After breaking his hip bone, Mr Subramanian* do not do much exercise as he feels tired and pain while walking. In the past, he will usually walk 20 minutes around his housing area 4 times a week.
Nutrition
Due to the condition his wife is facing, they usually eat outside and seldom cook as it is difficult to do so. He starts up the day by having a light breakfast, bread with coffee. During lunch, he takes a more heavy meal and at night he will usually have capati.
Connectedness
Mr. Subramanian* has a good relationship with his wife. They take care of one another as he does not want to burden and worry his son who is overseas. He is also close to his neighbours and will spend the evening talking to them.
Environment
The area where he lives in is said to be safe and clean. He enjoyed staying in his neighbourhood. However, mosquito fogging operation has been conducted by government health personnel indicating there are cases of dengue or the area is a high-risk zone.
Patient’s Perspective
Mr Subramanian* is at first doubtful he has dengue. However, after the consultation with the doctor, he is worried about his condition. This is because if he gets sick, there wouldn’t be anyone to take care of his wife. He does not want to burden his son who is staying overseas. The condition has affected his life as now, he isn’t as active as before. He constantly feels tired and finds it hard to do his daily routine. He stated that he does not have a choice in choosing health services but also said that the healthcare provided is not bad. Mr Subramanian* is very grateful that all the doctors have been really professional and kind in helping him with his disease. Throughout his experience, he has never had any bad experience in the clinic Though the waiting time is very long, he feels that it isn’t choice. There is nothing he can do about it as the clinic is the nearest public healthcare centre and he does not want to go to a private clinic or hospital as it is very expensive. He hopes that the government will do a better job in caring for the elderly. Besides, he wants more research to be done so that better medication can be produced to treat disease effectively.
Own’s Perspective
The feeling of being rejected by multiple patients and being rushed by the nurse to quickly get a patient is very discouraging. Through their non-verbal cues, I can see that some patients really do not want to be interviewed. Some of them frowned when they heard that the interview will take about 30 minutes long and told us they do not have the time as they will be entering the consultation room soon and after the consultation, they have to rush off to do their chores or work. The nurse who is in charge of us reprimanded us for informing the patient of the duration of the interview but I feel uncomfortable withholding the truth from them. When I managed to find someone to talk to, I was so grateful and thank him profusely. He was very open and nice to talk to. Talking to him makes me feel sad and I find it hard to continue interviewing him about his medical condition. It shows me how there are many people out there who need help. I feel helpless as I can do nothing to relieve him of his burden. This case commentary enables me to apply all that I have to learn in my studies to practical use. For example, the proper way to take a medical history and how to deal with emotion by being empathetic and understanding. We should also be observant and able to pick up cues. However, it also shows how different it is to take a medical history from a real person having problems than your friend role-playing the illness.
Conclusion
There are many factors that affect one’s health. It is not only about the disease but also about the people having the condition. We need to take into consideration many of the aspects that play a role in their life.
References
Ashcroft, RE, Dawson, A, Draper, H & McMillan, J 2007, Principles of biomedical ethics, 2nd edn, e-book, College of Medicine Chattanooga, Tennessee, viewed 21 May 2018, https://www.utcomchatt.org/docs/biomedethics.pdf
Davis, CP 2017, ‘Fever (in adults)’, eMedicine Health, viewed 15 May 2018, https://www.emedicinehealth.com/fever_in_adults/article_em.htm#what_are_causes_and_associated_symptoms_and_signs_of_fever_in_adults
Gill, BS 2017, What is dengue, viewed 22 May 2018, http://denggi.myhealth.gov.my/what-is-dengue/?lang=en
Gubler, DJ, Ooi, EE, Vasudevan, S & Farrar, J 2014, Dengue and dengue hemorrhagic fever, 2nd edn, e-book, Monash Universty Library, Malaysia, viewed 13 May 2018, https://www-cabdirect-org.ezproxy.lib.monash.edu.au/cabdirect/FullTextPDF/2014/20143309279.pdf
Kassim, PNJ & Ramli, N 2016, ‘ The inviolability of medical confidentiality in Malaysia: an analysis of the rules and exceptions’, IIUM Law Journal, vol. 24, no. 2, pp. 335-357.
file:///D:/Downloads/262-Article%20Text-979-1-10-20161231.pdf
Malaysia Health Technology Assessment Section (MaHTAS) 2015, Management of dengue infection in adults, viewed 13 May 2018, file:///D:/Downloads/CPG%20Dengue%20Infection%20PDF%20Final%20(3).pdf
Malaysia Prime Minister Department 2016, Eleventh Malaysia Plan, viewed on 13 May 2018, http://epu.gov.my/en/rmk/eleventh-malaysia-plan-2016-2020
National Health Service England (NHS England) 2017, Involving people in their own health and care: statutory guidance for clinical commisioning groups and NHS England, viewed 24 May 2018, https://www.england.nhs.uk/wp-content/uploads/2017/04/ppp-involving-people-health-care-guidance.pdf
Ng, CJ, Lee, PY, Lee, YK, Chew, BH, Engkasan, JP, Irmi, ZI, Hanafi, NS & Tong, SF 2013, ‘An overview of patient involvement in healthcare decision-making: a situational analysis of the Malaysian context’, BMC Health Serv Res, vol. 13, no. 408, viewed 15 May 2018, https://link.springer.com/article/10.1186/1472-6963-13-408
Phipps, ME 2018, ‘Ethical issues in doctor-patient relationships’, MED1011- Medicine, Lecture notes, Semester 1, 2018, Monash University.
Malaysian Medical Council 2011, Confidentiality guideline, viewed 15 May 2018, http://www.mmc.gov.my/images/contents/ethical/Confidentiality-guidelines.pdf
Satyanarayana Rao, KH 2008, ‘Informed consent: an ethical obligation or legal compulsion?’, Journal of Cutaneous and Aesthetic Surgery, vol. 1, no. 1, pp.33-35, viewed 13 May 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840885/
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