Bioethics

Please don’t assault my patient!

By Chris Rangel MD ⋅ September 20, 2007 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

Medical Ethics: You can’t force a patient to stay alive.

The patient is in his 50s and is suffering from a neurological disorder that has impaired his ability to breathe and swallow. He is dependent upon a feeding tube inserted into his stomach for nutrition and a ventilator inserted through a tracheostomy to breathe. He faces the prospect of being like this for the rest of his life.

The tracheostomy prevents him from speaking but he is otherwise completely awake and alert and is able to communicate by writing. He understands his diagnosis and prognosis.

The patient has some ability to breathe on his own and so the pulmonology service was trying to see if the patient could recover enough strength to come off the ventilator (weaning). Indeed, his pulmonary status gradually improved to the point that he was able to come off of the ventilator for short periods (breathing only from an oxygen mask placed over the tracheostomy tube).

Unfortunately he would eventually get fatigued and need to be placed back on the ventilator. It was during one of these trial periods that the patient refused to go back on the ventilator. He made it very clear (via writing) that he understood that he might die without the ventilator but that he didn’t want to live if he was going to be dependent on the ventilator for the rest of his life.

This was witnessed by the family, the nursing staff, and myself and was well documented. But the pulmonologists felt that the patient may not be capable of making his own decisions because the carbon dioxide level in his blood was rising as a result of his ventilatory failure. However, it was obvious that he remained clear headed and able to determine his own fate.

Then one of the lung specialists ordered that the patient be sedated and placed back on the ventilator. Hold on a sec! Isn’t that assault? Yes it is. But the specialists felt that from a liability standpoint, they could not be 100% sure that the patient is fully competent since he could not speak and he had a relatively high carbon dioxide blood level. They felt that this uncertainty could be brought up in court and used against them should the case ever go to trial.

Wait a minute! The family witnessed the patient communicating with the staff and they agree that he is competent and free to make his own decisions. All of this has been witnessed and properly documented. And nobody is talking about a lawsuit. As far as I know there are no issues of potential malpractice in this case. But the specialists felt that they should err on the side of keeping the patient alive since some uncertainty remains.

Sadly, the specialists are right. Not ethically right. They are legally right. They are playing the odds. Far fewer lawsuits are filed for similar cases where the patient is kept alive against their wishes then in cases where the patient died because a certain treatment was not given. There is also the practical aspect that time can be taken to make absolutely sure that the patient is competent, informed, and their wishes clearly known before treatment is withheld.

The downside of waiting to make absolutely sure of what the patient wants (or allow time for the patient to change his or her mind) is that this may prolong suffering before the patient ultimately is allowed to die. But this is what the patient wanted to avoid in the first place!