Leading Oncologist Overrode Patient's ITU Wishes, Tribunal Hears

Ian Leonard

September 17, 2021

MANCHESTER—A patient spent "10 days further deteriorating and dying on ITU" after world-renowned oncologist Professor Justin Stebbing overrode her wishes in the belief her lung cancer was "eminently reversible", a medical tribunal heard.

Prof Stebbing is appearing before a Medical Practitioners Tribunal Service (MPTS) fitness to practise hearing accused of failing to provide good clinical care to 12 patients between March 2014 and March 2017.

The 36 charges, 25 of which he's admitted, include inappropriate treatment of patients given their advanced cancer or poor prognosis, overstating life expectancy and the benefits of chemotherapy and continuing to treat patients when it was futile.

The tribunal heard about one female patient - referred to as Patient C - who'd been diagnosed with advanced lung cancer.

Prof Stebbing is accused of inappropriately escalating her care, which included providing assisted ventilation and prescribing second-line full-dose chemotherapy in the weeks prior to her death.

It's also alleged he failed to consider an appropriate ceiling of care with the specialist interdisciplinary team, failed to discuss a realistic assessment of the patient's prognosis with her or her family, and failed to obtain informed consent.

Prof Justin Stebbing

Intensive Care

Sharon Beattie, QC for the GMC, told the tribunal about a letter that Prof Stebbing wrote to a colleague which stated that while Patient C wanted intensive care as an option "she will not have non-invasive ventilation at any time".

The letter added: "But I've explained that I'm prepared to override that decision as I feel this is eminently reversible."

Ms Beattie asked Dr Nick Plowman, a defence witness in the case, whether intensivists would rely on an oncologist's opinion when admitting a cancer patient to ITU, and whether he agreed that Patient C's cancer was "eminently reversible".

He said it may have been "possible" to reverse the patient's cancer, but he described it as a "minority' rather than a "majority" chance.

Dr Plowman conceded that an intensivist would be guided by the oncologist on a patient's prognosis and the reversibility of their disease.

"If he [Prof Stebbing] said it very didactically, 'I can turn this patient around' then that would be wrong.

"If he said, 'It is possible to turn it around' as he did very successfully with Patient B [another lung patient] then that was reasonable.

"But he should not have said, 'I can turn this around.'"

Ms Beattie said an oncologist would need to have a "realistic" conversation with ITU colleagues and "couldn't work on the basis every patient is Lazarus".

And Dr Plowman agreed that it had not been realistic to categorise Patient C's cancer as "eminently reversible".

"Eminently suggests that on balance it's a majority chance of not being useful," he said.

"Whereas 'it is possible' means it is achievable."

Lymphangitis

Dr Plowman said he disagreed with GMC experts that the patient's lymphangitis had been progressing and she'd shown signs of an infection.

He also claimed the patient's first dose of chemotherapy had shrunk a tumour by 50%, which was "very unusual', and it had been "liminal" to give her further treatment.

But Ms Beattie said it would have been appropriate to establish a ceiling of care for the patient sooner but this had only been done 2 days before she died.

She said the patient's condition had continued to deteriorate following chemotherapy and she'd had a "prognosis of weeks".

The patient hadn't wanted to go to ITU and was uncomfortable with the prospect of ventilation and intubation, said Ms Beattie, and Dr Plowman agreed that a formal ceiling of care plan should have been in place when the patient was admitted to ITU.

Further chemotherapy had been "inappropriate", Ms Beattie said, and a "realistic assessment" of her prognosis should have taken place but she'd then spent "10 days just further deteriorating and dying on ITU".

MPTS Chair Hassan Khan asked Dr Plowman about the appropriateness of Prof Stebbing's comments about overriding Patient C's wishes.

"I would not have made that statement and proceeded to ventilation if the patient had expressed that wish," he said.

"I would not have gone against the patient's wishes if they were put as starkly as that, although I might well consult with the family into if there was a possibility of reversing."

Patient F

The tribunal also heard about another lung cancer patient - Patient F - who Prof Stebbing is accused of treating based on an "unrealistic" prognosis of 18 months.

The female patient had been admitted to hospital in a critically ill condition in March 2016 after undergoing a lung operation and immunotherapy.

The patient's DNAR order had been reversed, Ms Beattie said, because Prof Stebbing's prognosis "fed" decision-making by the ITU team.

Dr Plowman agreed the order should have still been in place when she was given chemotherapy and there was a "low probability", given her frail condition, it would bring any benefit.

Prof Stebbing faces other charges relating to Patient F of failing to provide a balanced decision and considering an appropriate ceiling of care with the specialist interdisciplinary team and failing to obtain informed consent for the patient's treatment.

Patient G

A third patient - Patient G - was allegedly given chemotherapy by Prof Stebbing when he was allegedly too unwell to receive it and his condition was rapidly deteriorating, and he died 4 days later.

The patient's lung cancer had spread to his liver and abdomen and when an intravenous line was inserted so he could receive the chemotherapy, he suffered a pneumothorax and a surgical emphysema.

Ms Beattie told the tribunal that "concerns" had been raised about the treatment by Prof Stebbing's colleagues at the London Clinic when the patient's condition deteriorated and his prognosis became "extremely poor".

Dr Plowman said the patient had reached a "critical stage" and it was "probably inappropriate" to give the chemotherapy.

But he added that if the patient's condition had improved there was a "minority" chance the treatment would bring some benefit.

The tribunal is continuing.

Ian Leonard is a freelance journalist experienced in covering MPTS hearings.

Credits:
Lead Image: MPTS
Image 1: Kerry Elsworth

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