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Case from last night.

Discussion in 'Emergency Medicine' started by edinOH, May 4, 2007.

  1. edinOH

    edinOH Can I get a work excuse? 7+ Year Member

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    77 yo bed-bound pt sent to ED from home with police initiated Order of Protective Custody secondary to comments made to neighbor about his desire to "kill himself with a gun." Pt is bed-bound after CVA several years ago with recently dx advanced lung CA. Palative care only. Hospice involved. Full code.

    I evaluate pt, dx with SI and UTI. Stable SaO2 low 90s on 3 liters. Base line hypotension 90s/50s. AOx3. Denies SI to us when he learns of intent to admit. Clear for transfer to our sister free-standing geropsych unit.

    psych kicks the guy back to me via EMS. State he is "too sick to be there". I politely ask them what they expect me to do about it. Crickets.

    Reeval. No change. Discuss condition with pt. Now DNR by my order and his wishes. Psych insists on medical consult to "follow along" in psych unit. Consultant agrees. Sent back to unit for eval of SI. Now that he is DNR they are comfortable accepting.

    My hands are tied because I have a police OPC as above requiring psych eval. He just wants to go home and die.

    In summary, terminally ill pt with low quality of life wants to die. I can't let him. Pt is sick enough for DNR order but not too sick for psych eval. Once the psych is able to note that the pt doesn't really want to die he will be allowed to go home and do just that.

    Our system is idiotic.
     
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  3. GeneralVeers

    GeneralVeers Globus Hystericus Physician 10+ Year Member

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    What is wrong with our society and medical system that we can't let old people die?

    I should be the one to decide how an when I die. When I'm old and infirmed, why can't I have someone give me a lethal dose of morphine? What is so wrong with this if I'm directing my own end?
     
  4. docB

    docB Chronically painful Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    I totally agree. I had a similar case a while back. Risk management wouldn't let me make the guy DNR because as a patient with suicidal ideation he was unable to make decisions for himself. Medically we all knew he was right but the risk managers have to head off the lawyers. He got admitted as a full code until psych could clear him to be allowed to make himself DNR. The really sad thing is that primary care is so bad around here that his suicidal ideation was the result of being a poorly cared for end stage CA patient who had never been told about hospice and just flet like he was a burden to his family.
    What hospice has patients who are full code? Why do they do these things?
     
  5. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    SCREW IT!
    In South Carolina, you don't have to be DNR to be hospice. I asked a hospice nurse about this as I showed my incredulity, and she agreed that it was uncommon and counterproductive, but didn't have a reason or solution.
     
  6. southerndoc

    southerndoc life is good Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Shows like ER and Rescue 911 have contributed to the misconception the public has that CPR revives people.
     
  7. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

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    SCREW IT!
    I can sell people on the DNR, though - I start out with "without a decision, we always err on the side of 'life', because we can't undo 'death'. However, what we do borders on barbaric. The only patient I've ever done CPR on that I didn't break a rib was a 42 year old man. Now, as I say, we can't undo death, so, if you desire, we will do everything we can to save your <whomever>, if his/her heart stops or s/he stops breathing. I just don't want you to be surprised by what you see, and there is a chance that, if it does happen and we save him/her, s/he may be on a machine to breathe, and likely would only last a day, if that."

    That usually seals the deal.
     
  8. edinOH

    edinOH Can I get a work excuse? 7+ Year Member

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    I'm more direct when it comes to selling it to the family.

    I say "If the good Lord comes down tonight to take (insert name here) home, do you want us to try to stop Him?"

    That usually works.
     
  9. southerndoc

    southerndoc life is good Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Heh, good one!

    Some people either fail to grasp the notion of resuscitation (thinking they will be revived after this long terminal illness that took them to begin with), are in denial, or their family simply gives them too much grief or they feel like it would help their family to know that everything was done to prevent their death.
     
  10. mikecwru

    mikecwru M.D. = Massive Debt 7+ Year Member

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    Maybe I'm jaded, but I don't think suicide should be illegal.

    We had a case where a guy popped himself in the head, but was awake enough to communicate. I can't remember all the details, but he was vent dependent and conveyed his wishes to be taken off of the vent. This was acceptable.

    The whole system is prone to circular logic. "I want to kill myself." Well, you're depressed, you can't make proper decisions. "How do you know I'm depressed?" Because you want to kill yourself.

    mike
     
  11. Frijolero

    Frijolero Member 5+ Year Member

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    Suicide isn't illegal, nor punishable. If you're talking about assisted suicide, well, that's obviously a different story.
     
  12. docB

    docB Chronically painful Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    It may not be technically illegal but if you express a desire to try it or if you try it unsuccessfully in our society we (and I do mean we since all EM folks have to participate in this farce daily) will arrest you and hold you until you no longer express a desire to do it. Telling someone you plan to rob a bank will not get you incarcerated anywhere near as quickly as telling them you want to off yourself.

    PS- I've had nore then one person dumped in my ED by the police for "homicidal ideation" after they threatened to kill someone. So in reality criminal ideation and suicidal ideation are handled about the same.
     
  13. Jeff698

    Jeff698 EM/EMS nerd 15+ Year Member

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    Here in Texas, we're required by law, in this circumstance, to ask if the person they intended to kill deserved it. Then, depending on whether or not we agree with them, we decide if we're gonna keep 'em or help 'em.

    Take care,
    Jeff
     
  14. mikecwru

    mikecwru M.D. = Massive Debt 7+ Year Member

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    Suicide is illegal in some states, although rarely punished, for obvious reasons, and what others have replied to you.

    Thanks for playing.

    mike
     
  15. Indiana is one of them....apparently you can get jail time for it but I've never heard of it actually happening. I would imagine because the ACLU would have a field day with it.

    But you're right, it shouldn't be illegal. I think we have a right to determine when and how we exit this world, and that should not be constrained by the misguided religious beliefs of others.
     
  16. EM2BE

    EM2BE Elf 7+ Year Member

    I'm just wondering how they would punish a person with a successful suicide attempt...would be interesting to see.
     
  17. southerndoc

    southerndoc life is good Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    In most states, suicide is one situation where an attempt is illegal, but success isn't a crime. Odd law, eh?
     
  18. docB

    docB Chronically painful Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Texas - Where "he needed killin'" is a viable defense.;)
     
  19. Frijolero

    Frijolero Member 5+ Year Member

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    You're right, partially anyway. There are some states where the law is still on the books, however, our lovely state, Ohio, isn't one of them. My reply was directed to your concern about your patient who wanted to off himself, presumably also in Ohio. Additionally, there are quite a few absurd laws that are still on the books that aren't enforced that nobody has bother to remove. While technically illegal is some states, suicide has never been punished in the USA.
     
  20. southerndoc

    southerndoc life is good Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Yes, like in the town where I grew up, it was illegal to drive a chicken truck down Main Street from 9 am til noon on Sundays.
     
  21. Bent Aub

    Bent Aub Cheese. Aub like cheese. 2+ Year Member

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    A cage in Texas.
  22. It's illegal in Indiana to have sex with a virgin. Even on her wedding night.....figure that one out.

    Of course, that's also the state where if you're in a bar band and you play "Louie, Louie" it's considered a obscene act and you can get 6 months in prison.
     
  23. Wow.....the folks from Cali must be packing some bigger weapons than I thought.

    "I swear officer, I have a concealed carry permit for my howitzer."

    OK, where do you get a permit for said mongoose? (BTW, I know the reasoning behind this law)

    Nice. Someone really thought that one out didn't they?

    :laugh:
     

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