Reference no: EM133852137

Question

F. L., a 20-year-old Pakistani boy suffered a near-drowning episode that compromised his central respiratory drive mechanism and left him neurologically devastated. His family was informed that life-sustaining medical interventions were futile. They agreed to move him to the Butterfly Room (a specialized palliative care room) to achieve a family-centered death. Orders not to resuscitate were written in a clear and detailed manner. All laboratory analyses were discontinued, and all monitors were removed. Medications were reviewed and all were discontinued. Morphine and lorazepam were added for the management of dyspnea, I.V. fluids were discontinued, and scopolamine was administered for terminal secretions. One intravenous catheter was left intact, but all other invasive monitors, such as nasogastric tubes, urinary and arterial catheters, etc., were removed. During his transfer from the ICU to the Butterfly Room, he remained mechanically ventilated.

Although F. L. has a small family, he belonged to a close-knit community. Thirty people of all ages came to be with him on his final day of life. They encircled the boy's bed, chanting but not touching him. After approximately 30 minutes, they approached the team and announced their readiness for the discontinuation of mechanical ventilation. One caregiver stated that she was unfamiliar with Pakistani traditions and customs, but had not observed anyone touching F. L. She suggested that if touching was allowable and desirable for them, they were welcome to do so. The whole spirit of the group changed, with the circle drawing nearer the bed and men openly grieving and weeping, holding the young man and their wives, as well as each other. People stroked F. L.'s face and body. After an hour, they again informed the team that they were now ready to have the mechanical ventilation discontinued.

F. L. was suctioned and extubated and needed little pharmacologic intervention. His loved ones chanted from the moment the endotracheal tube was removed. Each visitor, in turn, put small amounts of holy water in his mouth. Although the water bubbled out of his nose, a caregiver wiped it away, giving "permission" for the next person to engage in the ritual. After 27 minutes of non-stop chanting, F. L. died. A peaceful hush fell over the room, and all eyes turned to the same window, leading to the outside.

1. What culturally based beliefs and practices are evident in this case?

2. What are the strengths and weaknesses of the care reported in this case?