23 May 2011

A case study in applied ethics

In my professional life, one of the things I frequently have to do is tell someone that I am recommending a course of action that they may not be terribly keen on pursuing. And I know it when I am making the recommendation. "I'm sorry, sir, but I think we are going to need to admit you to the hospital/put this tube in your chest/cut off the remainder of your finger," etc. I am accustomed to getting resistance in these situations and having to convince the patient that there's a good reason to do what I recommend. Usually, patients exhibit good sense and comply. Sometimes they refuse. Generally, I am OK with that. It's the right of a patient to refuse treatment they don't want. I don't take it personally, but it can be a bit frustrating when you have to watch someone make a really bad decision.

But it does bring up an interesting and tricky issue: when is a patient NOT allowed to refuse care?

We had an illustrative and complex case recently along these lines. A young man, in his early 20s, was seen in the ER on three consecutive days for suicidal ideation and non-life-threatening suicidal gestures. In each case he was felt not to be eligible for detainment under our state's law (which sets a fairly high bar for involuntary treatment compared to many other states), and he was able to "contract for safety," for whatever that is worth, and so was released each time. A complicated overlying factor was his heavy dependence on opiates and benzodiazepines.

He returned to the ER following a motor vehicle accident. It was a single-vehicle accident where his car had left the road and hit a tree for no apparent reason. He appeared sleepy on the scene and roused with narcan pre-hospital; the medics assumed that he crashed because he was stoned. In the ER, he admitted taking some pills to get high, and admitted that he still felt somewhat suicidal, but denied that he was trying to kill himself by crashing his car. The urine toxicology test was positive for opiates and benzodiazepines, but a blood alcohol was negative.

He did have multiple injuries. Several broken ribs and pulmonary contusions and a small cerebral contusion. While he was in the ER, his oxygenation began to deteriorate and repeat chest x-ray showed increased opacification suggesting worsening pulmonary contusions/incipient ARDS.

I explained that he was going to require intubation and mechanical ventilation due to the severity of his lung injuries. He refused.

For those familiar with trauma, the early signs of hypoxia and worsening x-ray findings indicate a really bad lung injury which absolutely will require ventilatory support as a life-saving measure. There are not really any other compromise treatment options, at least none that offer reasonable expectations of making a difference.

At this time, the patient was alert and seemingly oriented. He was able to express that he understood that refusing intubation would lead to his death. He was unable to, or chose not to, articulate any reason that he did not want to be intubated. He stated to multiple people that he was comfortable with the idea of dying, and he felt at peace. He was adamant in his refusal of intubation.

At the time these discussions took place, he had received some pain medicine for the rib fractures. His oxygenation was borderline low at 89% on high-flow oxygen, but vital signs were otherwise more or less stable. No family was available. After some time in the ED, his oxygen levels began to decline further and the patient was no longer verbally responsive.

To summarize, this young man, with a long life ahead of him has a lethal injury for which he has clearly refused the only potential life-saving intervention. He has demonstrated the bare minimum elements of an informed refusal of care, and has done so consistently to multiple interviewers. However, his decision-making may have been compromised by his head injury, by low oxygen levels, or by the presence of intoxicants (both recreational and therapeutic). Other complicating factors include his latent suicidal ideation and speculation as to whether his injury may have been self-inflicted.

What would you do if you were the doctor in this situation (or the administrator/ethicist/judge called to offer guidance)? Would you provide supportive care and allow him to die, or would you violate his express wishes and intubate him?

Would it make a difference in your decision if you were told the survival rate for this injury was only 25% even with full treatment?

Would it make a difference if the patient were 75 instead of 25?

Does the possibility that he may have been suicidal invalidate his refusal of care?

Let me know what you think in the comments, and I'll fill in the outcome in a couple of days.


  1. An interesting question of what to do. We've always had it drilled into us that unless its in writing, ahead of time prior to injury, they are full code. Even if the guy has DNR/DNI tattooed across his forehead.

    Given his recent history I think you would be justified doubting that he is fully compos mentis.

  2. At that time, what was his capacity to make decisions? If he was still intoxicated from his overdose then he shouldn't be relied upon to make decisions for himself.

    Likewise, if he's actively having thoughts of suicide and has just likely acted on them, then can't he be treated against his will? Active suicidality and s/p suicide attempt ought to be enough to commit and treat someone. It may mean pushing induction medication in preparation for the intubation with him vocally refusing, but c'est la vie.

    Finally, perhaps there's a middle ground. Perhaps instead of intubating him you could control the pain from his broken ribs and work on his vent/oxygenation status. Maybe try ketamine and CPAP. If that doesn't work then continue down the DSI pathway a la http://emcrit.org/podcasts/dsi/ .

  3. Not a doctor, but it seems to me like you're not obligated to help him with his suicide. I say get him through this event, and let the chips fall. My feeling is that people who really want to kill themselves will get it done. This reminds me of the suicide-by-cop scenario, where the person provokes the police to use deadly force.

  4. I agree with Er Jedi and am worried that he was not actually "compos mentis."

  5. I'd say that there are two factors working in tandem to invalidate his refusal of care: the fact that he tested positive for psychoactive drugs and the fact that the injury may have been self inflicted (especially given his past suicidal ideation).

    I'd say the thing to do would be to intubate and ventilate him. Perhaps if/when he wakes up he could be interviewed by law enforcement with a knowledge of the crash site, and they could try to figure out, based on consistencies/inconsistencies in the story and other cues, whether the injury was self inflicted.

    If the injury was self-inflicted, I presume you're obligated to detain him, even under Washington's relatively loose state law. Right?

  6. Been in this situation a handful of times and I've always tubed em. There are so many good ways to explain why you tubed him but not many good ones to explain why you didn't. No way I let an otherwise healthy 20yo die in a trauma bay just because he says he wants to. His request to not be tubed could be passive suicide, altered mentation secondary to hypoxia, drugs.

  7. I think the key feature would be his judgement and insight. If it was a devout Jehovah's witness who lost a lot of blood in similar circumstances, would you violate his religious beliefs to save his life? If he can form an articulate reason to not want to be intubated (eg, violates his religion, puts undue stress on family, etc), I feel like I'd have to obey his wishes.

  8. My personal inclination would be to follow his wishes. I believe in pretty much absolute autonomy and the right of a person to make their own decisions (even really bad ones).

    The presence of drugs or alcohol does not necessarily make him "impaired". (I would argue that "sober" is a clinical diagnosis, not a laboratory diagnosis).

    However, my residency training was to treat, and I suspect that most of my current partners would also treat.

    Given that this is the "standard" in my practice envorinment, I suspect that I would most likely treat (as per ERMD's reasoning).

  9. There are four things at play here that are going against him being of sound mind that should allow the MD to override the client's decision making: the fact that he had been previously seen for suicidal ideation, that he has tested positive for drugs, his impaired oxygenation status, and that he crashed his car into a tree with no apparent reason.

    Can somebody clarify how much effect would the Narcan reversal would have had on restoring his mental status to make clear decisions? I've only seen it given when resps drop too low from narcs.

  10. I'm not a physician -- I'm a psychology intern right now -- so, from my perspective, I'd say tube the shit out of him. His mental status is really doubtful thanks to injury, drugs, and documented Hx rather persistent suicidality. I would not want to be explaining to anyone why I let this guy die. Regardless of age, regardless of survival rate of the procedure being contemplated.

    I always thought the standard of care was pretty much what ER Jedi said above: full code unless DNR/DNI in writing prior to injury.

    Can this event be part of an argument in favor of a mental health detention order?

  11. I'm going to break with the pack here. The guy wants to die. He probably just tried to kill himself.

    If you (meaning you, the medical profession, not you, the ER doc) can and will fix him so that he no longer wants to die, then you should do so. If you can't, then it seems to me the humane thing to do is to go ahead and let the poor guy die.

    It sounds like, if the guy had an incurable, horribly painful physical condition, you would be okay with not treating him. His horribly painful condition is mental, but I don't see why that should make a difference.

    Of course, this completely ignores any legal obligations you may have.

  12. It seems that he is not or likely not competent on several levels as described. Therefore, his refusal of ordinary treatment - in his circumstance and in our era - may not be reflective of his actual will. Therefore, my recommendation would be to intubate him even if contrary to his incompetent will. Should he demonstrate competency at a later date, at that point he does regain his autonomy.

  13. are you nuts? tube him. this charming polysubstance abuser's family will sue the bejeezus out of you if you let him die. and you're much more likely to lose that one than the one he will file for saving his life against his intoxicated, hypoxic, brain injured, psych disordered will.

  14. I find it is impossible for me to form an opinion without knowing the legal standards/rules that relate to restraining a person against his will. That is, what has to be shown to justify discounting his stated desire.

    My inclination is to feel like an adult has the right to insist that others not touch him, see, e.g., assault. And if there is an exception to that rule, namely because the person lacks the capacity to decide whether he wants someone to touch him, I would hope those conditions are clearly defined somewhere.

    At this point I don't have a way to evaluate.

    Nor do I know what I think morally. Is it your place to demand that someone go on living who has chosen not to? I don't think so.

  15. The guy's high and injured. Tube him and call the ethicist. Otherwise, you'll be sued by every other family member there is. He theoretically could be upset afterward but who cares? I'll take the risk of him going after me over the guilt of letting him die and the lawsuits from his loved ones.

  16. Several people have already hit the nail on the head. In this case, the consequences of not intubating him are potentially far worse than the consequences of intubating him.

    The key difference: you can always extubate him to die, should it later be shown and/or decided that is the best course of action for this patient; ergo, you can take it back. If he's dead, however, you can't take it back.

    At this point you're only expected to make the best decision you can with the tools that you have. Considering, as many have said, that he's questionably competent at best, that he's been severely injured, that he's high as a kite, and that he has the history of suicidality, the choice to save his life rather than prematurely kill him seems a rather clear one.

    Sure, you could skirt the rules and try BiPAP and all those other things, but let's face it: if he's a hypoxic trauma patient and this is more than just a pneumo/hemothorax, he's going to get worse before he'll get better and these patients almost invariably fail BiPAP if they're this hypoxic this early on. All you'd be doing is twiddling your thumbs while you try and get a hold of the ethicist or the family, at the price of potentially worsening his situation should he, say, aspirate.

    Unless I was absolutely certain that this was a truly informed decision made with a clear head and a spirit unencumbered by suicidality, I'd tube him, nevermind how highly I hold bodily autonomy.

  17. This is an interesting situation. I personally believe that people have the right to commit suicide. But in my experience, people who really want to die succeed in their suicide attempt. It's the "cries for help" that fail.

    Because of that and doubts about his competence due to intoxication/brain injury, I would intubate. When he recovers he can get counseling or fill out a DNR/DNI, or just do the job right the next time.

  18. I think it is beyond reasonable doubt that this patient cannot make an informed decision not only because he may be intoxicated but also because his reasoning may be impaired by suicidal tendencies. I would not change my conduct if this patient was 75 years old or had only a 25% chance of recovery.

  19. As a layperson, I'd agree with the "intubate" crowd. He's just been in a major accident, is low on oxygen, has exhibited suicidal ideation, and is intoxicated on one or more substances; his decision-making capacities are diminished at best in this circumstance. I'd make the same call if he were 75 (who's to say that he won't live to be 90 otherwise?), or if there was only a 25% chance of survival -- withholding potentially life-saving treatment from a patient you know to be potentially suicidal would make you complicit in their suicide, IMO, not to mention opening you up to lawsuits from any surviving family.

    Now, that being said, I'd think that a good next step is contacting his spouse (if he's got one), parents (if applicable), or person with a medical PoA (if there is one) to make further decisions until the patient sobers up, due to diminished capacity (and as a CYA move, should he later sue).

  20. I'm sure that the medically ethical decision would be to intubate. But I have this belief that everyone has the right to die, and that suicide is not a crime. For this, and many other reasons, I can't be in the medical profession.

  21. @Luis, re: "...tube the shit out of him."

    No, no. The tube would go in the other end.

    @callrespiratory - the only argument I would have with what you said is that I think it is harder to withdraw support once it has started, rather than not starting that support in the first place. That being said, though...

    The scenario you describe does not fulfill criteria for "informed DNR/DNI." In addition to the factors that everyone else has mentioned, the guy has a concussion! I'd intubate.

  22. As far as I know being suicidal means, especially after a probable suicide attempt that followed several others means he can't refuse care. I've seen similar cases with a tylenol OD and an immolation, both of whom were treated against their will (and eventually died). I think you involve the MHPs and the ethics folks and go ahead and save his life, or at least try.

    Survivability of the injury makes no difference to my opinion. Age might, at 75 we might consider that he had long standing wishes against intubation.

    Just my $0.02 worth. Also, glad my names not on that one. This sounds like litigation regardless of you decision. They usually leave us nurses and our shallow pockets out of these things, but not always.

  23. From a psychiatric perspective, I do not have enough data to determine whether or not he demonstrates the 4 Cs of decisional capacity.
    - Comprehension? (yes)
    - Communication? (yes)
    - Circumstances/Consequences? (probably)
    - Cognitive Manipulation? (No)

    We do NOT know whether he is able to rationally manipulate information, as he gives no reason for refusal of treatment.

    Given the available data, and the risk status (young patient with no terminal illness, persistent suicidality with suscpicious accident), my professional opinion would be that he lacks capacity and should be intubated.

  24. In my state, you're allowed to restrain and force necessary treatment on an intoxicated (drugs or alcohol) person against their "will". You would just have to sign a legal hold stating they were "chemically dependent" and there it is.

    Even if he wasn't suicidal, you can/should tube him. You most certainly can force treatment on someone that expresses suicidal ideation in my state as well. You most certainly have sufficient documentation of repeated statements of suicidal ideation over the course of several days, drug abuse, as well as a car crash immediately followed by a suicidal statement.

    Throw in a traumatic head injury and you have a perfect storm of irrational decisions.

    You'd be just about as stupid as can be if you did anything other than 4-point him and throw a tube down his throat. You can't let someone die just because they're high, head-injured and mentally ill and making "decisions" clouded by being high, head-injured and mentally ill.

    I can't imagine any state, even the state with the worst mental health treatment situation in the nation (isn't Washington rated lower than Puerto Rico or something?), would come down on you after repeated suicidal statements and a car crash with immediate suicidal statements following.

  25. @Matlatzinca: Harder yes, but not "impossible". Once he's in the refrigerated drawer in the morgue, ... well ... more impossible to take that back. It's the finality of the do-not-intubate outcome in a questionably competent patient that I balk at. Someone else suggested that if the patient really feels that way, he can get it in writing after he gets extubated. This may be part of the climate where I work (socialist Canuckistan) but I can't see a physician ever being faulted for saving this person's life, if there was a shadow of a doubt about his competence. Hell, I can think of a few situations where the patient was intubated against their understood wishes, because it was not properly expressed by the patient in writing, and this happened even with patients who were 75 or who had very poor prognoses. It's for situations like these why when I see my "regulars" (the old COPD patients on home oxygen) I make it a point to discuss intubation with them, to encourage them to think about it (if they haven't) and talk to their families about it (if they haven't) and to also get these wishes, once made, securely in writing, so that they can be honored.

  26. Bronx ER Doc6/02/2011 7:19 PM

    There's no ethical dilemma here, and a clear duty to act.

    Sedate, paralyze, drop the tube.

    Patient is intoxicated, clearly suicidal, and unable to account for his refusal of treatment.

  27. This reminds me of the Dax Cowart case. Briefly, he was severely burned in a natural gas explosion and treated for a number of years despite repeatedly expressing a wish to die. Important differences include your patient's hx of suicidality and intoxication, confounding his baseline competence.

    Acutely, paternalistic temporary life-saving measures are justified because they can buy you time to determine capacity. (Childress, "Practical Reasoning in Bioethics, 128). It's also concerning that although his refusal of treatment is consistent to multiple interviewers, he cannot express a rational reason.

    So intubate this guy. It is likely that his accident was another suicide attempt, and he should be committed and treated -- I'm surprised he wasn't before.

  28. It must be stressed that by obfuscating details for patient privacy, one could inadvertedly be skewing the response of those posting. A reckless suicidal youth is pitted against a compassionate, ethics-bound physician.

    What if the facts were closer to a patient readmitted multiple times because of life-threatening ailment, consenting to non-blood medical management? Might the attending who wishes to perform a seemingly routine procedure perceive a blood transfusion refusal as suicidal?

    Self-determination is a fundamental right granted to all patients. Is the person lucid, consistent in resolve? If not, is there a signed and witnessed medical directive confirming patient wishes? Are competent patient advocates or healthcare agents on hand? Can colleagues with more experience in such matters be consulted? Would it be advisable to transfer care to a physician skilled with similar cases?

    We must be careful not to manipulate a scenario in a manner that makes the patient seem incompetent in order to rally support for a preconceived opinion that conflicts with patient autonomy.

  29. There is no debate. If the patient adamantly refused the intubation THEN YOU DO NOT INTUBATE. I have an advanced directive stating that I will never permit intubation under any circumstances and that, along with this patients decision is legally binding. People have the right to choose what is done to them, noone else.


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