Right Way and Wrong Way: Making an Immediate Ethical/Legal Medical Decision
This thread is about what is the ethical and legal "right way" and what is
the "wrong way" for doctors and nurses in an emergency room to respond when they are in the act of attempting to save a patient's life and then after resuscitation, started earlier by the paramedics, and was in progress was told by the patient's surrogate to stop at once and let the patient die, not allowing the opportunity to taper off the resuscitation and observe possible recovery. Here is the scenario as written as the Case Study in the September-October 2015 issue ofthe "Hastings Center Report" for which I have received permission to reproduce here.
Robert F. is an eighty-five-year-old who suffered a heart attack at home in a rural location some thirty minutes from any major hospital. By the time the paramedics arrived, he was unconscious and nonresponsive. After spontaneous return of circulation, they began their standard procedure of therapeutic hypothermia. Robert's core temperature was lowered using ice packs, and cold intravenous fluids were initiated. Soon afterward, Robert started to shiver when his body temperature reached 35.6° Celsius. He was then given a bolus of vecuronium as a neuromuscular blockade, sedated, and intubated. He was also given a low-dose vasopressin for blood-pressure control. Shortly after Robert arrived in the emergency room, his daughter, his medical decision-maker, produced an advance directive documenting that her father has a do-not-resuscitate (DNR) order, and she demanded that the breathing tube and any other life-sustaining treatments be withdrawn immediately.
The medical staff is very reluctant to comply
with this demand for immediate action. Until the neuromuscular blockade wears
off, removing the ventilator will prevent Robert from breathing. Furthermore,
it may take some time to reverse the therapeutic hypothermia procedure to the
point that the patient is at normal temperature. In addition, therapeutic
hypothermia itself often causes arrest, so the patient may need to be
resuscitated again.
Should the staff wait until the patient is
warm or honor the decision of his daughter, who holds his medical power of
attorney?
To
stop all resuscitation at once will cause the patient to die while being
professionally treated and the patient's status for surviving without injury
would remain unestablished. This obviously was a moral "no no" by the
doctors and nurses since this act at this time might represent to them as
unprofessional "killing" of the patient. On the
other hand, to not follow the request of the patient through an advance
directive for medical care and the demand of the surrogate daughter, would mean
that the doctors and nurses were ignoring the legal and ethical autonomy of the patient.
So
tell me, which is the "right way" and which is the "wrong
way" for those medical professionals to act. ...Maurice.
Graphic: From Google Images
posted by Maurice Bernstein, M.D. @ 1:20:00 PM
10 comments
10 Comments:
Dr.B,
Actually this is an easy one. The patient's legally executed advance directive and medical power of attorney trump the "moral no-no" opinion of the physician in every case. The ER staff has no legal basis for refusing the direction of the properly designated surrogate to immediately cease resuscitation efforts. The surrogate clearly understands the patient will die as a result. Tell them the likely results of immediately terminating resuscitation - if they still insist. then immediately follow their directive.
In the scenario described, the only better thing would be if the patient also had a POLST/MOLST which, depending on it's specific treatment directives, would have prevented EMS from starting resuscitation in the first place. Unlike the advance directive, which pretty much only applies once you reach the hospital, the POLST/MOLST also apply to EMS first responders, and in most jurisdictions also exempts the patient from trauma protocols.
In states where it is available, I would strongly encourage anyone that has an advance directive that specifies DNR, DNI, AND, to have their physician execute a POLST/MOLST.
Contrary to popular belief, in most jurisdictions where they are authorized, the POLST/MOLST do not require that you be terminally ill to have one - one of the allowable reasons is personal beliefs or wishes, just like with the advance directive. If your physician balks at issuing one, it shouldn't be too difficult to find another that will. After all, life is a terminal illness - we're all dying...just some sooner than others.
Hex
Hex, you are absolutely correct about the need for the patient also above the signature of the physician have a POLST or MOLST completed. BUT the critical point to make: IN ORDER FOR THE FORM TO BE INFORMATIVE TO THE EMERGENCY MEDICAL SERVICE, THAT FORM MUST BE IN A LOCATION IMMEDIATELY AVAILABLE AND PRESENTABLE TO THE EMERGENCY MEDICAL PERSONNEL WHO ENTER THE LOCATION OF THE PATIENT.
With regard to the decision to terminate life-preserving management prematurely, the issue involves the fact that the physicians would be causing the patient's death not by allowing the underlying pathology (disease) to "do the job" but the death would be do primarily to the lethal consequences of shutting down the therapy prematurely.
Take this as an example of what I am writing about. You have a quadriplegic who has required breathing by the ventilator for 5 years and now wants the ventilator terminated and removed understanding that this act will cause the quadriplegic's immediate death. But what will be the primary cause of the patient's death if the vent is turned off? It will be the patient's underlying neurologic condition (permanent inability to breathe) that will cause death. In the Hastings Center Report case, terminating the supportive treatment prematurely may cause death not necessarily related to what medical condition the patient had leading to the resuscitation management (like the quadriplegic example) but will be due directly and independently to that initiated EMS management itself. To make this more clear: If a normal person is subjected to having the core body temperature lowered and had neuromuscular drug blockade to prevent shivering and in addition sedated and breathing carried out using a ventilator, to stop everything prematurely including the ventilator would very likely cause the death of the previously normal person.
The two deaths do not have the same lethal origins and pathway. And in the Hasting's case it was not the underlying condition causing death but what the EMS initiated and what the ER physicians did. There is a difference! ..Maurice.
I agree with Maurice. the question was what is the "right way" - not the legal way. I teach ethics CEs and this is always a tough one - legal is not necessarily "right" - and when they conflict, which way do you go? The other point in this case is, will death be caused by the patient's condition or the measures that were taken in the ER?
Excellent discussion topic, MB.
Mike Z in WV
Maurice,
Most physicians feel that they can do whatever they please without consequences. They can always justify it as medically necessary, emergency situation, etc. The rights of the patient must be absolute with NO exceptions.
“The rights of every man are diminished when the rights of one man are threatened.”
― John F. Kennedy
“Because to take away a man's freedom of choice, even his freedom to make the wrong choice, is to manipulate him as though he were a puppet and not a person.”
― Madeleine L'Engle
Let me give some examples of how many doctors think:
”Even a parent doesn't have the right to say what's appropriate for a physician to do when they're doing an exam. ” --Dr. Ramlah Vahanvaty (After forcing genital exams on 59 sixth grade girls without consent.) Source: The Dallas Morning News
The solution; The right to informed consent MUST be absolute, no exceptions, NO COERCION!
—Banterings
But, Banterings, in a case like the one presented on this thread, the "informed DISSENT" must be made available PRIOR to the resuscitation attempt otherwise the burden (legal or moral) of the patient's death due to improper management of the resuscitation process would be born by the physicians and nurses themselves. This case has no relationship to the reference you provided.
Again, if the EMS crew had been notified, in some way, by the patient or surrogate that resuscitation was unwanted, it would not have been started. But once, allowed to start, if stopped prematurely, the resultant death would not be a violation of the surrogate's informed dissent.
There is a difference, relative to consent, between the case you presented and the one on this thread. ..Maurice.
Maurice,
Honestly, I can say that I don’t have an answer when they are at this point. It depends on the person, daughter, the advanced directive; context that one can only get from being present in that situation. I am NOT saying that someone should put a pillow over his face.
My point is that regardless of what the patient wishes, the physician or staff can override those wishes without being held accountable. The advanced directive is pretty clear…
The following description is pretty telling of the attitude of the typical provider attitude;
"To stop all resuscitation at once will cause the patient to die while being professionally treated and the patient's status for surviving without injury would remain unestablished. This obviously was a moral "no no" by the doctors and nurses since this act at this time might represent to them as unprofessional "killing" of the patient.
The use of the word “professional” somehow nullifies patients wishes because he is not a physician. This also implies that there are times that the patient is treated (resuscitated) unprofessionally. Again the excuse is professionalism.
Let me throw this out there; Say in the course of being resuscitated, the patient is brought back, slips away, resuscitated, and so on repeatedly. Let’s say that it is a really bad process, his ribs are broken, he gains consciousness, and any other bad things one could imagine occur.
The family sues the hospital and the ED/trauma team for the unnecessary pain and suffering the patient experienced. The team defends the resuscitation as a single event.
Ethically should they try and defend themselves or accept the consequences of their actions?
Perhaps this is a better question to be discussed. I don’t think that there is any argument that when a mistake is made that physicians and medical staff should own up, apologize, and accept the consequences of their actions.
But in reality how often does this really happen. I would say almost never.
—Banterings
An anonymous visitor wrote the following to this thread today:
The family sues the hospital and the ED/trauma team for the unnecessary pain and suffering the patient experienced. The team defends the resuscitation as a single event.
Ethically should they try and defend themselves or accept the consequences of their actions?
..Maurice.
In answer to the question regarding right way and wrong way in making decisions regarding an individual case I believe you must finish what was started by the EMS team. This is a great case for people to take seriously when filling out their directives and then placing a copy on the refrigerator. After all, what good is it if you took the time to write out your wishes and the people who are called to your home during an emergency are unaware of those decisions? I wonder who made the phone call to the EMS and why they were not aware of the patient’s medical directives.
I am a registered nurse in the Albany New York area and am currently enrolled in a BSN program through SUNY Delhi. I have seen firsthand how patients are admitted to the hospital and then there is a fight between the family members about what should be done with the patient’s healthcare. If a patient has written advanced directives and their neighbors, family, friends, and medical personnel are aware of those wishes, then they are more likely to be honored.
Once the resuscitative measures were put into action then those actions must be carried through. Any consequences that would develop as a direct result of the actions already in place would be accountable to the medical team on site. I would not feel comfortable stopping all measures at the daughter’s request until we reversed the procedures put in place. Then when we are back at the state of health the patient was in before our intervention, the directive could be carried out.
Debbie Romano, RN
Great topic. I feel that if death would be a direct result of stopping treatment already underway then they should continue the treatment until they can reverse the effects of it. By the time the daughter came in the damage was done and the medical professionals in this example are obligated to continue.
A visitor wrote the following today:
""There is always water on the floor, and our doctors have been cleaning the floor. They pay no attention to the holes in the barrel."
Do you think that the decision by the ER physicians and nurses to continue active management was misdirected and perhaps something essential to the issue was unconsciously ignored? ..Maurice.
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