[Paleopsych] NYT: On a Matter of Life or Death, a Patient Is Overruled

[Steve Hovland]

And how do you feel about this?

Was death the worst option for this man?

What if our culture believed in reincarnation?


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Subject:	[Paleopsych] NYT: On a Matter of Life or Death,	a Patient Is Overruled

On a Matter of Life or Death, a Patient Is Overruled
NYT October 5, 2004
By SANDEEP JAUHAR, M.D.

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."

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."

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."

Outside, the sun was rising. 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."

Perhaps he's 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?

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.


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.

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?

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.

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.

http://www.nytimes.com/2004/10/05/health/05case.html
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