Providing Support Against the Patients Wishes adapted from On a Matter of Life or Death, a Patient Is Overruled, New

1. Providing Support Against the Patient's Wishes(adapted from �On a Matter of Life or Death, a Patient Is Overruled,� New York Times, Oct. 5, 2004) Virtual Ethics Committee December 11th (2009) Ethics Consultant Group

2. The patient: Mr. Smith Mr. Smith could not breathe. Bright-red blood, filling up the air spaces in his lungs, was spewing from his mouth whenever he coughed. "So what are you waiting for?" I asked the cardiology fellow on the phone, trying to rub the sleep out of my eyes. "Intubate him." "He says he doesn't want a breathing tube," the fellow replied. "He's going to die without it," I hollered. "I know," the fellow said matter-of-factly. "And I think he knows, too. But he still doesn't want it."

3. Medical history I sank onto my living room sofa. What to do? Mr. Smith had come so far since his heart attack. Cardiac catheterization. A drug-coated stent to open up a blocked coronary artery. Intravenous blood thinners to keep the stent from clotting. Was it going to end like this? "This is a reversible complication," I told the fellow. I had seen it before with aggressive blood thinning. With a few days of ventilatory support, the bleeding should stop, we would be able to pull out the tube, and he would walk out of the hospital. "What do you want me to do?" the fellow replied. "He's refusing."

4. Medical course of events He said that he had already tried the usual measures short of intubation: supplemental oxygen, diuretics, a pressurized face mask. "Do you think he has decision-making capacity?" I asked. If not, we could make the decision for him. "I think so," the fellow replied, his voice thick from lack of sleep. "He apparently told the residents several days ago that he never wanted to be intubated." "He can't do this to himself," I said. "Try to talk to him again. I'm coming in."

5. The cardiologist weighs in Speeding to the hospital on a lonely stretch of freeway, I mulled over the options. As far as I could tell, there were only two: we could continue the current treatments and watch him die. Or we could intubate him against his wishes. From my car, I called the cardiologist who had performed the catheterization. "Intubate him," he said immediately. I explained that Mr. Smith did not want a breathing tube. "Who cares?" he cried. "He's going to die! He's not thinking straight."

6. Paternalism or beneficence? Perhaps the cardiologist is right, I thought. After all, who in his right mind wants to die? Were we not asking too much of Mr. Smith? Patients have a hard time properly weighing their options under the best of circumstances. In an emergency like this, how could we expect him to make the right choice? As an experienced doctor, wasn't I in a better position to make Mr. Smith's decision than Mr. Smith?

7. Where do we go from here?

8. Quick Poll What should the attending physician do in this case? Honor Mr. Smith�s previously stated wishes; provide comfort measures only Contact the patient�s surrogate for clarification of his wishes Intubate the patient; consent is not required in such emergency situations and should be presumed for Mr. Smith in light of the other treatments he has received for his condition

9. A decision is made When I got to the cardiac care unit, a crowd of doctors and nurses was at the patient's bedside and an anesthesiologist was preparing to insert a breathing tube. The cardiologist I had just spoken with took me aside. "He's breathing at 40 times a minute and his oxygen saturation is dropping, so I made the decision to intubate him." I nodded quietly. I had made the same decision in the car.

10. Central line placed Once the breathing tube was in, blood started rising in it like a red column. Nurses had to scramble for face shields and yellow gowns to protect themselves from the red spray. Pretty soon, someone was pouring brown antiseptic soap onto Mr. Smith's groin in preparation for a central intravenous line. As needles started piercing his skin, Mr. Smith started swinging wildly. In intensive care units, the steamroller of technology starts moving quickly, flattening all ambivalence.

11. The attending�s ambivalence Eventually, with sedation, Mr. Smith settled down, and the critical care unit staff settled in for a long period of observation. If we had gambled right, he would recover within a few days. "If you get through this," I whispered to Mr. Smith, "I hope you can forgive me." I have never been able to balance satisfactorily in my own mind the twin pillars of modern medical ethics: patient autonomy and the physician's obligation to do the best for his patient. As a doctor, when do you let your patient make a bad decision? When, if ever, do you draw the line? What if a decision could cost your patient's life? How hard do you push him to change his mind? At the same time, it is his life. Who are you to tell him how to live it?

12. The medical aftermath Mr. Smith had an unusually rocky hospital course. The bleeding in his lungs continued for several days, requiring large blood transfusions, but it eventually stopped. His blood pressure was too low, then too high. He had protracted, unexplained fevers. After a few days, I ended my service as the attending physician in the critical care unit. A week later, I heard that Mr. Smith's condition had improved. A week after that, a fellow stopped me in the hall to tell me that the breathing tube was out.

13. Bedside conversation When I went to see him, I realized that I had never really looked at him as a person. He was a tall, muscular man in late middle age, with a broad forehead, a flat nose and high, handsome cheekbones. I went to his bedside and introduced myself. He didn't recognize me. "When you were really sick, I was one of the doctors who made the decision to put in the breathing tube," I said. He nodded, eyeing me curiously. "I know you didn't want the tube," I went on, "but if we didn't put it in, you would have died." He nodded again. "I've been through a lot," he finally said, his voice still hoarse from two weeks of intubation. "I know," I replied. "But thank you," he said.

14. Discussion question #1 Was Mr. Smith�s desire to not be intubated an informed decision? Is a patient directive binding when it has no apparent medical context? (E.g. �no tubes�) Was Mr. Smith�s decision consistent in light of all of the aggressive treatments that he had recently allowed? In what circumstances (if any) may a physician override a patient�s wishes?

15. Do other factors trump advance directives? Survey containing six hypothetical cases involving seriously ill patients. Each case contained an explicit living will with potential conflict between the directive and either the (1) prognosis; (2) wishes of patient�s family/friends, or (3) quality of life concerns. Treatment decisions by physicians (internists & residents) were not consistent with the advance directive in 65% of cases. �Quality of life, treatment outcomes, and family preferences were frequently more decisive for physicians. However, these other factors may reflect the physicians� values rather than those of the patient.�

16. AMA Code of Medical Ethics (Council on Ethical and Judicial Affairs) 2.20 Withholding or withdrawing Life-Sustaining Medical Treatment Though the surrogate�s decision for the incompetent patient should almost always be accepted by the physician, there are four situations that may require either institutional or judicial review and/or intervention in the decision-making process: No surrogate Dispute among family members and no designated surrogate Health care provider believes that family or surrogate decision is clearly not what the patient would have decided when competent A health care provider believes that the decision is not a decision that could reasonably be judged to be in the patient�s best interests.

17. Discussion question #2 Should patients like Mr. Smith be �consented� (�re-consented�?) when they are under duress? If Mr. Smith had not previously said that he did not want the tube, would these physicians have asked for his consent? Is there any reliable tool to assess capacity in these situations?

18. Discussion question #3 How do you interpret the following exchange? Attending: "When you were really sick, I was one of the doctors who made the decision to put in the breathing tube. I know you didn't want the tube, but if we didn't put it in, you would have died.� Mr. Smith: "I've been through a lot.� Attending: "I know." Mr. Smith: "But thank you."

19. Bibliography �On a Matter of Life or Death, a Patient Is Overruled,� by Sandeep Jauhar, M.D. New York Times, Oct. 5, 2004 (Council on Ethical and Judicial Affairs) Code of Medical Ethics: Current Opinions with Annotations. American Medical Association, 2000, p.55-71, 82-85. Enough: The Failure of the Living Will. Angela Fagerlin,� Carl E Schneider.�The Hastings Center Report.�Hastings-on-Hudson: Mar/Apr 2004. Vol 34, Iss�2;�pg.�30. �Difficult End-of-Life Treatment Decisions: Do Other Factors Trump Advance Directives?� Steven B. Hardin, MD; Yasmin A. Yusufaly, MD. Arch Int Med/Vol 164, July 26,2004. �Missed Opportunities during Family Conferences about End-of-Life Care in the Intensive Care Unit.� J. Randall Curtis et al. Am J Respir Crit Care Med Vol 171. pp 844�849, 2005.