|ETHICS IN MEDICINE University of Washington School of Medicine
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Sample Case AnalysisCase:
John, a 32 year-old lawyer, had worried for several years about developing Huntington's chorea, a neurological disorder that appears in a person's 30s or 40s, resulting in uncontrollable twitching and contractions and progressive, irreversible dementia. It typically leads to death in about 10 years.
John's mother died from this disease. Huntington's is autosomal dominant and children of an affected person have a 50% chance of inheriting the condition. John had indicated to many people that he would prefer to die rather than endure the progression of the illness. He was anxious, drank heavily, and had intermittent depression, for which he saw a psychiatrist. Nevertheless, he was a productive lawyer.
John first noticed facial twitching 3 months ago, and 2 neurologists independently confirmed a diagnosis of Huntington's. He explained his situation to his psychiatrist and requested help committing suicide. When the psychiatrist refused, John reassured him that he did not plan to attempt suicide any time soon. But when he went home, he ingested all his antidepressant medicine after pinning a note to his shirt to explain his actions and to refuse any medical assistance that might be offered. His wife, who did not yet know about his diagnosis, found him unconscious and rushed him to the emergency room without removing the note.
How much weight should John’s preferences (especially his attempt to end his life) carry in managing his emergency and subsequent clinical care?
There are 2 diagnoses/prognoses that merit consideration. The underlying chronic disease of Huntington's is incurable and symptoms progress with a bleak long term prognosis. However, there are effective treatments available for the acute diagnosis of drug overdose including gastric lavage (pumping his stomach), emetics, antidotes, and/or activated charcoal (to prevent undigested drugs from entering his blood stream); supportive treatment following the initial treatment; and medications to ameliorate the underlying depression. How does the diagnosis of Huntington Disease affect our response to the acute condition? We know that the standard of practice is to assume that patients admitted for suicide attempts lack decisional capacity.
We know from the patient's suicide note that he is refusing all medical treatment. However, what do we know about these statements of preference? Were they informed? Was the patient competent to make that decision? The answers to these questions remain unclear, but we do know that the patient does not have decision making capacity for the present decision of whether to proceed with the gastric lavage. Is there a surrogate decision maker available?
Quality of Life
Life with Huntington's can be difficult. John was familiar with the quality of life associated with living with Huntington's as he watched his mother die of this disease. On the other hand, John does have a supportive family and continues to be able to work for the time being. How should the diminished quality of life that is anticipated in the future affect current clinical management?
Several factors in the context of this case are significant. While the patient has a legal right to refuse treatment, he is currently unconscious and his surrogate (his wife) is requesting treatment. There are also certain emergency room obligations to treat emergent conditions. How should the emergency staff weigh the various competing legal and regulatory duties?
John has indicated through his note that he refuses potentially life-sustaining treatment, but his competency to make decisions is questionable in the context of attempted suicide. Also at issue is the distinction between the acute and chronic conditions.
The precedent for cases such as this one is fairly clear. When the patient's preferences are unclear or health care providers have reason to believe a patient’s decision-making capacity is compromised; the acute condition is easily treatable; and the harm of not treating is very great, emergency medical treatment of the immediate life-threatening condition is provided, creating an opportunity to talk with the patient about his preferences regarding his chronic condition at a later time and to treat any underlying depression that may have contributed to his suicide attempt.
Notice that the facts of this particular case determine whether the precedent case is applicable. If the medical team was familiar with this patient's expressed preference to refuse any medical treatment and if the available treatment for the acute condition was considerably less certain to be effective, the case could be decided differently. The clinicians would look for a different precedent. .
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