Question of the Week # 33

•A 33-year-old man with advanced AIDS is brought by ambulance to the hospital after collapsing on the street. Paramedics resuscitated and intubated the patient for ventilatory support and transported him to the hospital while in an incoherent, agitated state. Physical examination and laboratory studies confirm an extensive pneumonia involving the entire left lung. Shortly afterwards, his designee demands that the patient be taken off the ventilator. The designee produces a copy of the patient’s living will indicating the patient wishes no life support and that his designee is to make all medical decisions if he becomes incapacitated. The patient’s previous hospital record contains a copy of the same living will. Which of the following is the best course of action?

( A ) Maintain the patient on the ventilator •

( B ) Contact the patient’s parents •

( C ) Contact the hospital’s attorney •

( D ) Remove sedation and wean the patient •

( E ) Provide sedation and pain medication and extubate the patient

14 Responses

  1. e

  2. E ) Provide sedation and pain medication and extubate the patient

  3. e

  4. e

  5. e

  6. E

  7. e

  8. E

  9. E

  10. eee

  11. E

  12. Patient autonomy is respected first. Extubate the patient and keep him on the pain meds and sedation. “E”

  13. I am truly in love with this blog. It is a wonderful opportunity to learn, share and get instantly corrected. Please join me in thanking Dr Archer. As a tribute to him for my success in Step 3, from personal experience, I would like to say that Dr Archer Red’s teaching liberated my thinking from subtle misconceptions, rejuvenated my self- confidence living as an old IMG and also boosted my Step 3 scores like no other prep did.

    Patient autonomy followed by Substituted Judgement followed by Best Interest Standard? That’s the normal routine.
    Patient autonomy > Substituted Judgement > Best Interest Standard
    (Patient is right > Relative is right > Doctor is right)
    Basically we don’t decide for the patient if somebody else can do that reasonably well.
    Best interest standard is only applied first in an emergency when patient has never clearly mentioned to anyone what he or she wants;
    OR if he or she is incapable of making health decisions from birth like severely mentally handicapped individual AND clearly there is an advantage of intervention over palliative care or vice versa AND (very importantly) relatives concur.
    OR in a child to save life or limb threatening emergency.

    On the other hand, when a substituted judgement is available but it is NOT in the best medical interest of the patient and it is inflexible, (with some exceptions) the case goes to ethics committee and (as last option) to court. What I mean is that if a decision clearly sounds like the designee’s personal wish or desire rather than patient’s desire and it is harmful, then it is contentious.
    For instance in one case, a designee (someone with power of attorney) requested to feed an incapacitated patient on NG tube with castor oil and alternative medicines. The patient, a 70 year old lady had advanced PTB, she was comatose and on ventilator and she did not explicitly say that she wants castor oil while on NG tube and ventilator. The designee remained adamant after educational counseling.
    Best interest standard protects the patient when the substituted judgement is clouded or when it is, within reasonable doubt, a designee’s personal desire or wish (projected over the patient) AND it is clearly harmful. Ethics committee is consulted. And court is consulted as a last option for conflict resolution and to legally exercise Best Interest Standard for mentally incapacitated patients.

    If an individual is drunk (intoxicated- blood alcohol > 0.5%), can we use best interest standard? YES. Can we use substituted judgement? YES, Which one do we use first? Substituted judgement, as long as, it is not contentious that this is a designee’s desire NOT the patient’s likely wish. For instance, designee requesting administration of medical marijuana. If it is contentious, we gently educate the designee. If he or she refuses to comply, we go to ethics committee to seek permission to exercise best interest standards. Intubation, DNR and withdrawal of life (ventilator) support are exceptions to this rule. There is no contention about these. A physician can not question a designee on these if there is a WRITTEN advanced directive or power of attorney. (oral informed consent is not acceptable in ERs). Physician MUST however provide palliative and/or supportive care even on extubated patients, DNR, or on patients weaned off life support. If the designee also objects to supportive care, educate him or her. If he or she refuses, involve the ethics committee. If the ethics committee fails to resolve this problem, then the court would be the last option. Supportive care is a basic right (turning an unconscious patient, feeding, cleaning, toileting) that can not be denied. Medications (especially pain meds, routine diabetic or hypertensive drugs) are not basic right but fall in the shady area. If the patient is clearly in unbearable pain or designee requests to withhold a patient’s routine medication (one he was used to before incapacitation), this case requires education of the designee. If this fails, the case goes to the ethics committee, next option (last option), would be court.

    Severely dehydrated delirious ADULT patient going into shock? Designee REFUSES administration of IV Fluid resuscitation. Answer, give only oral fluids.
    Severely dehydrated delirious CHILD going into shock? Designee refuses IV, answer, chase him out of the ER (kiding), administer IV fluids.
    Designee REQUESTS administration of Hepatitis B & Typhoid & Cholera vaccine or castor oil treatment, answer, education of designee and if he refuses, ethics committee followed if necessary by court.

    My answer is also OPTION E.

    Thank you.

    References:
    1.http://www.ethics.va.gov/docs/bkissues/Newsletter_2003Summer_Ethics_Rounds_Substituted_Judgment.pdf
    2. Zajdel J, Zajdel R, Dziki A, Wallner G. Alcohol-intoxicated patients at admission room – analysis of legal aspects of rendered medical services. Ann Agric Environ Med. 2012; 19(4): 701-706.
    3. http://www.treatmentadvocacycenter.org/get-help/be-prepared-for-an-emergency/342
    4.http://www.naemsp.org/Documents/Position%20Papers/POSITION%20EthicalChallengesinEMS.pdf
    5. http://en.wikipedia.org/wiki/Legal_guardian

  14. …and the official answer from Dr. Red is…?

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