Sunday, August 30, 2009

Doctor, I want to die

Several years ago, I was called by the ER to manage a young man I'll call Dan who was becoming acutely paralyzed. It turned out that he was the only one in the family to eat his wife's home canned spinach and had developed acute botulism. He needed rapid intubation, then transfer to the ICU for on going ventilator and supportive care. He received anti-toxin as soon as we could get it. His wife was devastated and needed a lot of support from their pastor and the social worker. Dan required tube feeding, an air bed to prevent pressure skin ulcers, close monitoring of his ventilator and a close watch for infections. The anti-toxin had no measurable benefit, so on we went with care. His wife, I'll call Sue, was with him constantly and the two kids aged 2 and 4 we're allowed to visit at the family's discretion.

The medical prognosis was that of complete recovery but it was going to take a few months for his paralysis to clear. After about 6 weeks, Dan was able to communicate that his life dependent on a ventilator and with full body care was not worth living, even if he might recover. The psychiatrist judged him competent and not clinically depressed, but it was possible that he could not able to realize the fact that he indeed was going to get better. I told Dan, after discussing with my colleagues, that we couldn't agree to remove the ventilator because of his excellent prognosis. Our ethics committee agreed with this stance although the usual ethical principle of autonomy seemed to be violated here. Basically the other ethical principles of beneficence and non-malfeasance were the ones that seemed most appropriate to us.

Dan made it clear that he wanted a lawyer. Fortunately, I think, the lawyer went along with the wife and medical team and told him he couldn't go for a court order or guardianship in these circumstances. We were aware of famous "wrongful life" cases but felt that we needed to be an advocate for this man's healthy future and that there were legal risks in either course.

Personally in the ICU I have, to respect the patient's wishes, withdrawn life support in terminally ill patients. This is generally done with consensus of all the loved ones and occurs daily in all ICU's across the country. Ethics committees are invaluable in the more difficult cases.

But Dan's case was unique - and he did survive and returned to his life as a husband, father and productive citizen. When I saw him later in my office, I asked, "So how do you feel about our keeping you going against your wishes." He paused, then said "Well, I'm very happy to be alive but there's still a part of me that's pissed off."

No comments:

Post a Comment