Doctor Ethics: Saving a Life Without Consent

[alingy1]

A person needs to undergo surgery. Someone shot him. He will die in three hours. No one knows him. He has no family. He comes to the hospital and his mental situation is bad. He seems to be crazy and says irrational things. He can't think or make decisions for himself. You are a medical doctor. Do you go in surgery to try and save his life even if the patient says he doesn't want it (you clearly understand that the choices he makes are not necessarily logic)?

So, I basically came up with this question. What does the doctor have to do? Does he have any consequences if he doesn't follow the patient's desires? Does he have to consult someone? What would happen if this situation wasn't urgent (say he will day in three months because of cancer)? What do you do?

 

[DiracPool]

A person needs to undergo surgery. Someone shot him. He will die in three hours. No one knows him. He has no family. He comes to the hospital and his mental situation is bad. He seems to be crazy and says irrational things. He can't think or make decisions for himself. You are a medical doctor. Do you go in surgery to try and save his life even if the patient says he doesn't want it (you clearly understand that the choices he makes are not necessarily logic)?

So, I basically came up with this question. What does the doctor have to do? Does he have any consequences if he doesn't follow the patient's desires? Does he have to consult someone? What would happen if this situation wasn't urgent (say he will day in three months because of cancer)? What do you do?

Your confusing an ethics question with a legal question. The legal issues vary from state to state as far as mental competence and decision making as far as I know. So let's leave those legalities out for my post and focus on the ethics question. I would say sedate the nutcase, do the surgery, and when the patient "comes around," do a mental evaluation from there.

 

[alingy1]

True, but the legality part is also part of the situation. They are very closely linked. I think your option makes sense. You take the basis of being a doctor, saving lives, and you apply it while knowing the patient can't think.

 

[berkeman]

In California (and many other states), the patient has to be a mentally competant adult in order to refuse care. In the situation you described, the field EMS personnel (Paramedics & EMTs) and the doctors and nurses in the hospital would not accept this patient's refusal of care.

 

[bobze]

A person needs to undergo surgery. Someone shot him. He will die in three hours. No one knows him. He has no family. He comes to the hospital and his mental situation is bad. He seems to be crazy and says irrational things. He can't think or make decisions for himself. You are a medical doctor. Do you go in surgery to try and save his life even if the patient says he doesn't want it (you clearly understand that the choices he makes are not necessarily logic)?

So, I basically came up with this question. What does the doctor have to do? Does he have any consequences if he doesn't follow the patient's desires? Does he have to consult someone? What would happen if this situation wasn't urgent (say he will day in three months because of cancer)? What do you do?

From a doctors standpoint you would do the surgery. You are given legal leeway when the matter is concerning emergent situations. So long as you document properly, what led you to make these decisions then you should be okay. This is called implied consent--for when a patient is delusional, intoxicated, mentally unfit or otherwise incapacitated to make a medical decision and prolonging the delivery of a procedure to properly consent a next of kin could result in a poor prognosis.

This extends to parental/child relationships as well. For example, suppose you had a mother and her newborn and you as the doctor had reasonable suspicion the child had Hirschsprung disease. You went to talk to the mother to explain your concern and the need for a barium enema to confirm the diagnosis and treat it accordingly. The mother refuses because she doesn't believe anything is wrong. You would do the procedure anyway in this case and go to probate court later, because the consequence of forestalling the procedure, diagnosis and treatment is grave.

Situations that are not emergent are handled differently. As a provider you have to determine competency. If people are competent they are allowed to make stupid decisions, there is nothing you can do about that as a doctor other than provide them with informed consent. In areas where competency is sketchy or you are uncomfortable in determining it you can request a competency evaluation (in most states handled by a psychiatrist, but some states psychologists can do this assessment as well). If the patient is not competent to make medical decisions you go to court and probate them. The judge usually places the patient's medical decisions in the care of family, the medical team attending to the patient or the state (which usually just follows the medical recommendations the attending doctor).

 

[alingy1]

Bobze, the mother in your case is aware of the situation and the risks since you went to explain it to her. She finds that nothing is wrong according to her. Why wouldn't you accept her choice as she becomes competent by your informing her? The disease the you mentioned, how long will it take it to hurt the baby? (I'm no doctor so I don't know.)

EDIT: According to a website, it could kill in two days if the mother ignores vomiting of the child and dehydration etc. But, wouldn't you still have time to rexplain the implications of the mom's decision to her and inform her adequately? I don't think you the mother would let you do the procedure if she was the one with the disease. in this case, she is the baby legal responsible, and she doesn't want it.

 

[alingy1]

http://www.guardian.co.uk/society/2009/oct/01/living-will-suicide-legal
In this case, the woman was left to die... But, she was depressed. Doesn't that make her mentally unfit?

Even if she wasn't, suicide is a crime. Wouldn't you be an accomplice by not helping her?

 

[bobze]

Bobze, the mother in your case is aware of the situation and the risks since you went to explain it to her. She finds that nothing is wrong according to her. Why wouldn't you accept her choice as she becomes competent by your informing her? The disease the you mentioned, how long will it take it to hurt the baby? (I'm no doctor so I don't know.)

EDIT: According to a website, it could kill in two days if the mother ignores vomiting of the child and dehydration etc. But, wouldn't you still have time to rexplain the implications of the mom's decision to her and inform her adequately? I don't think you the mother would let you do the procedure if she was the one with the disease. in this case, she is the baby legal responsible, and she doesn't want it.

Yes, even if you explain the risks of hirschsprung disease and she refuses you do the barium enema anyway. Most states in the US have laws that protect children form negligent decisions on the parts of their parents, and health care practitioners as well in emergent situations. Hirschsprung's disease, untreated, would be considered an emergent situation. Depending on the health of the baby and severity of disease you could have serious consequences, like death, in a day. Even if it turned out to be less severe and the baby could live, for say a few weeks without intervention, you could still have long term sequelae that you'd (as the doctor) potentially be held responsible for.

 

[alingy1]

Thanks! Seems logical. What are your thoughts on theweb link?

 

[bobze]

http://www.guardian.co.uk/society/2009/oct/01/living-will-suicide-legal
In this case, the woman was left to die... But, she was depressed. Doesn't that make her mentally unfit?

Even if she wasn't, suicide is a crime. Wouldn't you be an accomplice by not helping her?

I'm not familiar with the laws in the UK. However, in regards to ethics a living will provides the patient with autonomy if filled out when a patient is competent to make medical decisions. It states what kinds of interventions a patient would like to receive from medical professionals. If she filled it out and was competent then a practitioner is ethically obligated to follow those advanced directives regardless of how a patient ends up in a hospital.

Whether she had capacity to issue those directives is another issue. From the article it appears that the treating doctor, as well others called in for second opinions stated she had capacity. In which case, legally and ethically you are bound to follow the patients wishes. Like I said above, if a patient has capacity you can't stop them making bad decisions--You can only inform them of the consequences of those decisions and what options (medically) are available to them. Intervening when you shouldn't would violate patient autonomy, one of those ethical values found in that oath we all take.

 

[alingy1]

If the mother had the disease and she refused, would you consider her negligence and give her the procedure? Being a doctor sure is a hard job

 

[bobze]

In the second link I provided above if you scroll down the section titled "conflicts between autonomy and beneficence", they do a pretty good job of summing up how Western society, or at least particularly in the US those values are "ranked". Normally we give greater weight to a patient's wishes if they have capacity to make their medical decisions than we do to beneficence (acting in a patient's best interest).

 

[alingy1]

Very informative article. The term "mentally competent" is very vague though. How could you classify a depressed person?

 

[bobze]

If the mother had the disease and she refused, would you consider her negligence and give her the procedure? Being a doctor sure is a hard job

No. An adult that has capacity to make their medical decisions can make bad ones. Even at the cost of their life. If you have consented them and informed them and they still choose to refuse a life saving procedure there is nothing you can do, but respect their decision.

A child (in the example I provided above) is different. They cannot have capacity to informed consent and informed consent is made by proxy--their legal guardians. In most case that will be respected, however if a decision is made that could cause grievous harm or loss of life that guardian decision can be ignored (in an emergent situation) or taken away from the guardian if not immediately necessary (through the court).

The basis of that is; while a guardian makes the medical decisions for someone without capacity (a child in this example), the law and ethics dictates that when the child comes of age to have capacity what would they choose? Most "reasonable" (legal jargon) people would choose to have a life saving or morbidity reducing intervention. Ergo, you as a physician, act in the best interest of the patient (beneficence), not the guardian.

 

[bobze]

Being a doctor sure is a hard job

You're telling me. You go to medical school thinking its all going to be science, medicine, rainbows and unicorns, only to discover a significant portion of your class load your first two years is given over to ethics and legal topics

 

[bobze]

Very informative article. The term "mentally competent" is very vague though. How could you classify a depressed person?

Its is, something more akin to ambiguous legal jargon than medical jargon. I've run out of time for the evening though and unfortunately need to be back at the hospital in 8 hours (after a 16 hour day ) which means I need to get some shuteye!

However, this is a pretty good article on determining decision making capacity:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181079/

 

[BruceW]

The entire issue is one big grey area. Even if the person is determined to be capable of making rational, sane decisions, then their wishes are not necessarily going to be listened to. For example, if they chose not to undertake surgery that would save their life, I'm pretty sure that they will be forced to undertake it anyway, right? Or maybe I misunderstood this?

 

[bobze]

The entire issue is one big grey area. Even if the person is determined to be capable of making rational, sane decisions, then their wishes are not necessarily going to be listened to. For example, if they chose not to undertake surgery that would save their life, I'm pretty sure that they will be forced to undertake it anyway, right? Or maybe I misunderstood this?

I think you misunderstood. If someone has capacity to make a medical decision nothing is going to be forced on them. You can choose not to have a medical procedure done to you, even if it life saving.

If a person is unconscious, there are no advance directives on file, there is no easily available surrogate decision maker or someone doesn't have capacity, then normally doctors would do an intervention on the grounds that is what most reasonable people would choose.

 

[BruceW]

really? I don't think so. Maybe I'm wrong though. I don't know much about it.

 

[bobze]

really? I don't think so. Maybe I'm wrong though. I don't know much about it.

You are.

I'm not sure where you got the idea that medical procedures are forced on people, but that is incorrect. Like I said, anyone with capacity can refuse any kind of medical intervention they wish. Even if that intervention is required to save their life. Can't really be more clear than that.

 

[berkeman]

You are.

+1.0

 

[BruceW]

OK, you sound pretty sure, so I'll assume you are right about this. I think I got this idea because they can force-feed you, even if you are sane, rational, and want to die. I guess this is not a 'medical procedure' so it does not fall under the same category.

 

[russ_watters]

OK, you sound pretty sure, so I'll assume you are right about this. I think I got this idea because they can force-feed you, even if you are sane, rational, and want to die. I guess this is not a 'medical procedure' so it does not fall under the same category.

Yeah, that's wrong too:

Force-feeding is the practice of feeding someone against their consent, and is not an acceptable practice in the medical community.
Nutrition support therapy is only to be administered when medically necessary, such as with gastric obstruction, swallowing disorders etc, and only to be administered with a patient's full consent. Some of the many reasons a person may refuse to eat are hunger strike, psychiatric problems, eating disorders, and Alzheimer's/Dementia. Despite the fact that it may be necessary for the person to eat, medical professionals are not to administer feeding without consent from the patient. [emphasis added]

https://en.wikipedia.org/wiki/Force-feeding#Medical_uses

 

[bobze]

OK, you sound pretty sure, so I'll assume you are right about this. I think I got this idea because they can force-feed you, even if you are sane, rational, and want to die. I guess this is not a 'medical procedure' so it does not fall under the same category.

Like I said, if you have capacity you can refuse any medical intervention, not just procedures, you want. See Russ's post.

 

[Philosophicall]

Your confusing an ethics question with a legal question. The legal issues vary from state to state as far as mental competence and decision making as far as I know. So let's leave those legalities out for my post and focus on the ethics question. I would say sedate the nutcase, do the surgery, and when the patient "comes around," do a mental evaluation from there.

Better to be safe than sorry.
Once you have been able to assess his mental health, alive, you have a less chance of being accounted for a "letting die" blame.

 

[alingy1]

Hmm... In another scenario, in which the shot person doesn't seem deluded, if he refuses to have this operation, wouldn't that choice make his thoughts irrational? I read the link that bobze gave. But, the cases of emergent scenarios is still a grey area. Since the doctor doesn't have time to diagnose the mental condition of the patient, shouldn't the one irrational fact of refusing treatment be enough to consider him probably mentally unfit to take decisions? Ergo, making him have the operation?

 

[jim mcnamara]

There is a protocol. I do not feel like citing it here right now. A protocol is a series of determinative steps to decide things like "intervene or not"

My basic response to your question(s):

1. I think you may not have read what what Bobze said.
2. Medical Science is guided by ethical guidelines - that is a very carefully stated set of 'how-to' steps for virtually any scenario.  Ever hear of 5150?
3. You are assuming "stuff"  - because it seems logical  to you within the bounds of your assumption set - please give credit to people who have done this for years.  Their assumption set may transcend anything you know.

Medical folks are not dummies. And they have LOTS of training. You are speculating probably with a limited background and playing 'What If'. That is not the best thing here on PF.

Please reconsider.

 

[jim mcnamara]

5150: I put it down here for those interested enough to slog onward.

http://en.wikipedia.org/wiki/5150_(Involuntary_psychiatric_hold )

 

[franklinwu]

A person needs to undergo surgery. Someone shot him. He will die in three hours. No one knows him. He has no family. He comes to the hospital and his mental situation is bad. He seems to be crazy and says irrational things. He can't think or make decisions for himself. You are a medical doctor. Do you go in surgery to try and save his life even if the patient says he doesn't want it (you clearly understand that the choices he makes are not necessarily logic)?

So, I basically came up with this question. What does the doctor have to do? Does he have any consequences if he doesn't follow the patient's desires? Does he have to consult someone? What would happen if this situation wasn't urgent (say he will day in three months because of cancer)? What do you do?

if a person does not have the capacity to make an informed decision for surgery (ie he is delirious, or he is in an acute psychotic state and was suicidal), then his refusal is not valid. if it's life threatening, the doctor will be obligated to perform a life saving procedure. If it's not life saving, then the patient can be admitted to treat the delirium and sort other things out until it gets better and the procedure can be postponed.'

for example, if i was in the streets and i tried to stab myself to death, i would be immediately taken to the ER. I tell the ER doctor that I'm trying to kill my self and thus do not operate on me. if the ER doctor realizes that I'm psychotic and suicidal, I would be put on 4 point hard restraints and taken to the OR anyways. once my medical condition clears, I would then be admitted on a 5150 hold and taken to psych hospital.