Wednesday, December 15, 2010


Diogenes once famously searched for an honest man.
Remember that parable as this story unfolds.
We're all aware, possibly too aware, of the phrase "death with dignity". We heard it often enough during the Terri Schiavo case, when Sen. Majority Leader Bill Frist magically diagnosed a patient in a vegetative state from a thousand miles away using remote viewing. This stream of consciousness is not about that case. That, believe it or not, was too cut and dried to really interest me, beyond the asshatical way the Republicans rode to her "rescue".
As if.
No, the conundrum I'm thinking of is even more difficult, even more visceral.
The question before you all is, when does "death with dignity" cross the line into suicide, assisted or not?
Let's say the patient has a living will, in which he refuses all invasive medical procedures except pain relief. Let's say further this living will can only be triggered in three cases: 1) The patient is non-responsive (unconscious), 2) the patient is terminal, or 3) the patient is conscious but has incurred brain damage sufficient to render them non-responsive.
Now, let's say this patient is admitted to the hospital after a fall. Broken clavicle, nothing too serious, but his age (ed. note 85) and general health make releasing him immediately a risk. The patient then spikes a fever as he's being treated for the fracture. The hospital decides to admit him after more than 24 hours in the ER. The healthcare proxy is admitted and submits the form, and begins consultation. Seems like a routine treatment scheme, so that proxy agrees with treatment.
As he arrives at his room, the patient's BP begins to spike as well. The hospital gives him appropriate medicines and he begins to stabilize.
Now the fun begins. His O2 saturation levels, which for any normal person are in the mid-90% range, start to decline. The pain of the fracture makes taking a deep breath difficult, and the general health-- obesity, fluid build up associated with congestive heart failure, and so on-- make pumping blood through the body difficult. Fluid begins to build up on the lungs, further complicating matters.
The patient is offered an O2 mask, which he refuses, violently. since it's a non-invasive procedure, the hospital sedates him and slips on one of them nasal-thingies. The sat rate stabilizes, but shortly thereafter, begins to decline.
A partial pressure mask is offered. The patient again violently refuses, and again, since it's non-invasive the hospital sedates and now restrains the patient, and places the mask.
The O2 sat rate still isn't responding. The healthcare proxy is notified, and asked if intubation for ventilation (forcing air into the lungs) would be ok. After ascertaining the dilemma, and with the reassurance that the intubation would be brief at most, the proxy agrees.
Now the fun starts. The patient is being weaned off his sedation, since the lungs need to start working on their own for him to be taken off intubation. The patient awakens, furious.
At no time prior to the intubation was the patient ever unconscious (except to sleep, of course). The "knock out" was necessary, presumably, to place the tube in. The patient, a stubborn cuss, simply refused to answer any questions, despite clearly being conscious and aware of his surroundings. This is why the proxy was consulted. He immediately rushes to the hospital, living will in hand, because he never figured he'd need this for a fracture. Silly proxy!
The proxy now insists the tubes be taken out. The doctors refuse. In fact, the doctors ask to be another tube in, a central line, since the patients veins in his arms are collapsing from all the O2 blood tests. The proxy refuses, at first. The proxy, in front of the doctors, asks the patient "Do you need any medicines? Do you want anymore tubes inserted? Do you want these tubes taken out?"
The patient answers, in sum, no more.
The proxy turns to the doctors, who had been unable to get any kind of response from the stubborn patient, and says "Well? What are you waiting for?"
The doctors mention that it will take a while to initiate the procedure: first, there's paperwork, then a behaviorist must be consulted, then the medical board of the hospital has to authorize it.
The proxy says, "Yea. And...?" The necessary forms are presented.
A little while later, the ethicist sits with the proxy and asks for some background details. The patient is clearly depressed, and has been for some time (e.g. all his life). The proxy mentions that the patient has been trying to commit suicide by, errr, proxy, refusing to take his medications, refusing to see doctors unless they come to him, refusing to be admitted to either a nursing home or assisted living facility and basically slowly withering away in his apartment, since he can't walk the stairs anymore.
The ethicist consoles the proxy about the difficulty of the decision and the need to remove the tubes, but, as she puts it, "the hospital is not in the business of assisting suicides".
Making the proxy feel guilty about the decision to intubate, of course.
The ethicist then makes the following offer: Give the doctors time to get the tubes out safely, with the satisfaction that she might breathe on her own after consultation with an intensive care specialist, if in return the patient agrees to be more cooperative.
Here comes Diogenes. She then says to the proxy, "I'll see if I can lie to her into believing that it will only take a day or so".
A lying ethicist. Interesting.
The patient has made it clear he wants to die with dignity. The proxy supports this decision, and not reluctantly, but made the mistake of trusting the doctors who said intubing the patient would only be for a short while, until he could breathe on his own.
...which, by the way, turns out he can, since after this discussion, the ventilator was turned off and the CPAP function turned on (air is not forced in, but is maintained at a higher pressure than normal to assist in breathing). The lungs are functioning OK, and the O2 sat rate is stable at 94%. Hours later, the ventilator is turned back on in order to allow the patient some rest and to let his lungs have a break overnight.
The doctors still believe it's a suicide request, and are probably not being fully forthcoming with the patient or proxy.
So the patient requesting to commit suicide or for the chance to die with dignity?
Thoughts? And as a bonus question, what would you do next?

UPDATE: Things took a turn for the worse yesterday. The O2 sat rate dipped, and the ventilator was kept on. After an examination by the intensivist and a neurologist (low oxygen = brain damage, just a matter of how much), and a negotiation between the proxy and the medical staff, it was agreed that if the patient did not show improvement by this morning, the hospital would agree to terminate life support.

It shouldn't have been a negotiation, in my book, nor should the proxy have had to be consulted, except as to the timing of the withdrawal.

I understand the conditions of the hospital. For every patient they screw up on, it costs five more patients appropriate care in terms of time, resources and scared doctors. The policies and the procedures they follow are designed to avert risk.

Still, I can't help but think this was a situation where everyone, even the doctors, had clear-cut instructions, and that the care of the patient is primarily medical but secondarily about the quality of his life.