ethics question

[lasek]

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This case has been bugging me all day today. Does anyone have any ideas? I'm taking care of this 47 year old guy with poorly controlled DM, multiple amputations, blind, severe back pain preventing ambulation, severe HTN (more than 200/100) and ESRD requiring dialysis (plus some minor stuff). He has no friends or family he is in touch with, lives in a nursing home. Today he refused any further treatment including dialysis because "he can’t tolerate his lifestyle, and since no cure is available what’s the point of continuing treatment."
So here is the dilemma, psych consult stated that the patient is competent (which everyone else on the team agrees with) but has mild to moderate depression (which I think is very questionable, and the attending says to just go with what the psychiatrist says). Because of the depression he is unable to refuse life saving procedures. For now we convinced him to resume his treatment and start on an SSRI, so it’s not an imminent issue yet. But if he refuses treatment the plan is to reconsult psychiatry and if he still refuses then involve the court system. I've found several articles that concluded that mild to moderate depression by itself is not a major factor when it comes to patients making decision about life saving procedures. I’m not sure what the legality of the issue is.
It just seems like I’m the only person thinking that this guy has a right to refuse treatment. I have to agree with the patient, the treatment will definitely not cure him and will most likely have little impact on his quality of life except to extend it. Am I wrong to think that its ok to let him go? I talked to the attending about this, but he insists on continuing to treat. Although I'm a bit uncomfortable with it but it’s not to the point that I can’t deal with it. Plus its a pretty good learning case, and I only have 3 days left on the rotation. Is it bad to ask to be removed form the case? Is there a usual procedure for dealing with these issues? Or should I just do what the attending says since he's in charge. Does anyone think that b/c the patient is depresed we can overrule his decision?

 

[watermen]

This case has been bugging me all day today. Does anyone have any ideas? I'm taking care of this 47 year old guy with poorly controlled DM, multiple amputations, blind, severe back pain preventing ambulation, severe HTN (more than 200/100) and ESRD requiring dialysis (plus some minor stuff). He has no friends or family he is in touch with, lives in a nursing home. Today he refused any further treatment including dialysis because "he can’t tolerate his lifestyle, and since no cure is available what’s the point of continuing treatment."
So here is the dilemma, psych consult stated that the patient is competent (which everyone else on the team agrees with) but has mild to moderate depression (which I think is very questionable, and the attending says to just go with what the psychiatrist says). Because of the depression he is unable to refuse life saving procedures. For now we convinced him to resume his treatment and start on an SSRI, so it’s not an imminent issue yet. But if he refuses treatment the plan is to reconsult psychiatry and if he still refuses then involve the court system. I've found several articles that concluded that mild to moderate depression by itself is not a major factor when it comes to patients making decision about life saving procedures. I’m not sure what the legality of the issue is.
It just seems like I’m the only person thinking that this guy has a right to refuse treatment. I have to agree with the patient, the treatment will definitely not cure him and will most likely have little impact on his quality of life except to extend it. Am I wrong to think that its ok to let him go? I talked to the attending about this, but he insists on continuing to treat. Although I'm a bit uncomfortable with it but it’s not to the point that I can’t deal with it. Plus its a pretty good learning case, and I only have 3 days left on the rotation. Is it bad to ask to be removed form the case? Is there a usual procedure for dealing with these issues? Or should I just do what the attending says since he's in charge. Does anyone think that b/c the patient is depresed we can overrule his decision?

Continue treating him.

1. Everyone is afraid of getting into any legal issue. So, just treat him. Consequences of not treating him with his current depression will attract those lawyers if he dies?

2. You only have 3 more days. Just go and write 3 more notes and get it done.

3. Is he DNR or Full code? If he is Full code, then not treating him is unethical. Even if he is DNR, you should still continue his current medication. The only way he can choose to shorten his life is to be non compliance.

 

[8744]

This case has been bugging me all day today. Does anyone have any ideas? I'm taking care of this 47 year old guy with poorly controlled DM, multiple amputations, blind, severe back pain preventing ambulation, severe HTN (more than 200/100) and ESRD requiring dialysis (plus some minor stuff). He has no friends or family he is in touch with, lives in a nursing home. Today he refused any further treatment including dialysis because "he can’t tolerate his lifestyle, and since no cure is available what’s the point of continuing treatment."
So here is the dilemma, psych consult stated that the patient is competent (which everyone else on the team agrees with) but has mild to moderate depression (which I think is very questionable, and the attending says to just go with what the psychiatrist says). Because of the depression he is unable to refuse life saving procedures. For now we convinced him to resume his treatment and start on an SSRI, so it’s not an imminent issue yet. But if he refuses treatment the plan is to reconsult psychiatry and if he still refuses then involve the court system. I've found several articles that concluded that mild to moderate depression by itself is not a major factor when it comes to patients making decision about life saving procedures. I’m not sure what the legality of the issue is.
It just seems like I’m the only person thinking that this guy has a right to refuse treatment. I have to agree with the patient, the treatment will definitely not cure him and will most likely have little impact on his quality of life except to extend it. Am I wrong to think that its ok to let him go? I talked to the attending about this, but he insists on continuing to treat. Although I'm a bit uncomfortable with it but it’s not to the point that I can’t deal with it. Plus its a pretty good learning case, and I only have 3 days left on the rotation. Is it bad to ask to be removed form the case? Is there a usual procedure for dealing with these issues? Or should I just do what the attending says since he's in charge. Does anyone think that b/c the patient is depresed we can overrule his decision?

Yes. It is bad to ask to be removed from the case. Dude. It's not even your problem as you are a medical student and therefore not responsible in the smallest degree for this patient.

While I agree with you, your attending is operating out of a highly developed sense of duty to the patient and is not being malicious, cruel, or incorrect in any way and I suggest you need to pick your battles carefully. This is not one you need to pick. If anything, in his secret heart your attending probably wishes this patient would just go away, fall into a hole, and never bother him again. I bet he's not even a paying customer so your attending is certainly not expending all of this effort for any personal gain.

 

[lasek]

Continue treating him.

1. Everyone is afraid of getting into any legal issue. So, just treat him. Consequences of not treating him with his current depression will attract those lawyers if he dies?

2. You only have 3 more days. Just go and write 3 more notes and get it done.

3. Is he DNR or Full code? If he is Full code, then not treating him is unethical. Even if he is DNR, you should still continue his current medication. The only way he can choose to shorten his life is to be non compliance.

He's not DNR, but i think that will change tomorow. He's for the most part stable, and we dont think he will be crashing any time soon.
Who is going to sue if his family doenst even know he's in a hospital and he says if they knew wouldnt really care, and he's got no friends?

 

[lasek]

Yes. It is bad to ask to be removed from the case. Dude. It's not even your problem as you are a medical student and therefore not responsible in the smallest degree for this patient.

While I agree with you, your attending is operating out of a highly developed sense of duty to the patient and is not being malicious, cruel, or incorrect in any way and I suggest you need to pick your battles carefully. This is not one you need to pick. If anything, in his secret heart your attending probably wishes this patient would just go away, fall into a hole, and never bother him again. I bet he's not even a paying customer so your attending is certainly not expending all of this effort for any personal gain.

I have no idea about insurance, but it sucks that he's getting treatmetn which he probably doesnt need, and deffinetely doenst want. I understand why the attending is continuing to treat, but he agreed the patient is competent. Just make your own decisions, dont just agree with the psychiatris who said "... but on the other hand the patient is probalby competent and i never lost a case in court yet. " and contradicted himslef at least 5 times when asked about what he thought. Guess I'm jsut frustrated about it.

 

[8744]

I have no idea about insurance, but it sucks that he's getting treatmetn which he probably doesnt need, and deffinetely doenst want. I understand why the attending is continuing to treat, but he agreed the patient is competent. Just make your own decisions, dont just agree with the psychiatris who said "... but on the other hand the patient is probalby competent and i never lost a case in court yet. " and contradicted himslef at least 5 times when asked about what he thought. Guess I'm jsut frustrated about it.

Oh, I totally agree with you. I think the average survival time on dialysis for all patients is five years and the elderly and those with many comorbidities are the ones bringing the average down. Dialysis is not a benign therapy, it just happens to beat dying for most people which is why they put up with it.

On the other hand, I can understand somebody not wanting to do it.

I really hate to see the old, demented, stroked out, ESRD patients. They just truck them in from the nursing homes like so much meat, dialyze them, and send them back to another couple of days of laying in their own urine developing bed sores. Not to mention all of the money we spend staffing ICUs to take care of the large percentage of patients who in a rational society would be sent either to their homes or hospice to die with some dignity instead of providing ACLS practice for the residents.

 

[SurgeryChef]

Continue treating him.

1. Everyone is afraid of getting into any legal issue. So, just treat him. Consequences of not treating him with his current depression will attract those lawyers if he dies?

2. You only have 3 more days. Just go and write 3 more notes and get it done.

3. Is he DNR or Full code? If he is Full code, then not treating him is unethical. Even if he is DNR, you should still continue his current medication. The only way he can choose to shorten his life is to be non compliance.

Absolutely agreed. As a med student I wouldn't even get involved in hashing this out with your attending. It's nice to be bright eyed, bushy tailed and full of trust in the patient and the system, but the guy in charge has to be thinking about other issues. Wait and see if the guy's depression improves with the SSRI (as I'm sure you know - it can take weeks) and then let the team decide. This isn't an ER case and I agree with the poster who said non-compliance is the only way he's going to go.

 

[edmadison]

I agree with the above posters that the best all around course is to wait and see what the effect of the SSRI is. Depression certainly comfounds end-of-life determinations. That be said, if this gentleman has decision making capacity (appropriate term rather than competance) then to treat him against his wishes is assault. One way you can help this man is to get SW or whoever and get an advanced directive on the chart. This is more than a DNR. Thus, if he does have the big stroke, he will not be needlessly flogged with IV/NG feeding.

Ed

 

[lasek]

thanks guys. i've stayed with the case, and the patient's going back to the nursing home tomorow after dialysis. it still sad because i feel like the patient was forced into the treatment. the psychiatrist basicaly told him that if he doesnt agree to it, then the decision will be up to the court. well, hopefully its for the best.

 

[Hodad]

Are there any legal protections for the patient? Ie, if he refuses treatment, isn't it possible he can sue the doctors for treating him in certain instances? Ie, if you stick an IV he refused to have can he argue along the lines of assault or somesuch? Privation of freedom if he's kept interned against his will? If the psychiatrists declared him competent, then there would seem to me like there's not any legally binding reason to not comply with the patient's wishes in this case for the rest of the staff.

 

[lasek]

Are there any legal protections for the patient? Ie, if he refuses treatment, isn't it possible he can sue the doctors for treating him in certain instances? Ie, if you stick an IV he refused to have can he argue along the lines of assault or somesuch? Privation of freedom if he's kept interned against his will? If the psychiatrists declared him competent, then there would seem to me like there's not any legally binding reason to not comply with the patient's wishes in this case for the rest of the staff.

well, there is presumed consent for certain things. when you go for a checkup and the doc draws blood, you didnt formally consent to it, but you didnt specifically refuse either. if the patient specifically refuses an IV (and there is no question of patient's competency) i doubt most docs would do it. i cant see problems with starting an IV going as far as an assault charge, but it wouldnt surprise me if it did.

in this particualr case the psychiatris was really on the fence though. he left it at "patient is probably competent, but call me if the patient refuses again because he may not be in the right state of mind to refuse treatment."