pedro_md Posted December 12, 2007 Report Share Posted December 12, 2007 Say patient X informs you, his doctor, that he does not want to be intubated/put on life support under any circumstances in the event anything happens to him. One day, the patient is involved in an accident and taken to the closest ER, where he is resuscitated and intubated/put on life support by the ER staff. At this point, the patient is in a coma. You, as his doctor, gain knowledge of his situation and go the the ER where he. Given that he has informed you that he would not want to be intubated/put on support, should you pull the plug and allow him to die? Clearly, this is not euthanasia and you would not be actively killing the person, but you would be allowing the patient to die. Should or should you not pull the plug before the patient regains his senses? Assume no evidence of brain injury. Likely he will make it out of the coma; it's just a matter of time until he does. So, to pull or not to pull? Link to comment Share on other sites More sharing options...
Rock* Posted December 12, 2007 Report Share Posted December 12, 2007 This scenario is really vague. Is the pt giving you a DNR request in a family practice visit or is he telling you this while he's hospitalized and he's assigned to you? Either way, it's unlikely that this scenario will ever occur--As a family doc, a patient is unlikely to be sick enough to randomly ask you for a Do Not Resuscitate request. If he does, you'd better determine his understanding and competency in making such a decision. If the pt tells you this while he's hospitalized, it would've been in his chart and the emerg doc would see the request and honor it when he comes in after an accident. Link to comment Share on other sites More sharing options...
The Law Posted December 12, 2007 Report Share Posted December 12, 2007 Why would anyone, if they're going to be in a coma for a very short time even suggest this? It's like saying, "oh you're going to be alive and kicking in a few days, but I'm going to kill you anyway." I really don't see this as being a realistic ethical scenario, or one that a doctor would have to face ever. Now, if they sustained serious brain injuries and had to be kept on life support for the rest of their life - now that's a different issue. Link to comment Share on other sites More sharing options...
pedro_md Posted December 12, 2007 Author Report Share Posted December 12, 2007 MAYBE I wasn't clear enough, but in this scenario, you are the family doctor of the patient. The patient does not believe in resuscitation and, as such, requested that no form of resuscitation ever be performed on him. He communicated this wish to you during a routine visit to the office. The patient was in overall good health prior to the accident. Unfortunately, for the patient, he was involved in a car accident and when transported to the ER, CPR and intubation followed. The hospital staff had no knowledge of his request. Link to comment Share on other sites More sharing options...
The Law Posted December 12, 2007 Report Share Posted December 12, 2007 If you know he is going to come to in a short period of time, then I would not "pull the plug." To do so would not even be a "sympathetic death," it would almost be like murder. You do have to respect the patients' wishes, but in this instance, to keep him or her on life support temporarily isn't a complete violation of those wishes. This is not a long term thing, but rather, a short term scenario. It's important to keep in mind, the patient did not wish to be placed on life support - but now that this has happened without your knowledge, and you know that his or her prognosis is good, it would be completely ridiculous to take him or her off of it. Link to comment Share on other sites More sharing options...
a41 Posted December 12, 2007 Report Share Posted December 12, 2007 If the patient strongly believed that he/she should not be resuscitated under any circumstances, he/she would probably keep these instructions on his/her body in such an event. It would be stupid of them to tell a family doctor these wishes since it's highly unlikely that a family doctor would be treating the patient in an emergency scenario. Link to comment Share on other sites More sharing options...
Julie Posted December 13, 2007 Report Share Posted December 13, 2007 True. If you want something similar that may be a bit more realistic : I have read of cases where a pt has a serious degenerative illness & because of that signs a DNR, which happens to be not very specific (ie doesn't state particular circomstances, etc.). Later something totally unrelated to the degenerative illness happens (ie car accident) and the patient needs to be rescucitated to survive. If he is, the prognosis is very good. Is it ethical to do so? Link to comment Share on other sites More sharing options...
Dante Posted December 13, 2007 Report Share Posted December 13, 2007 yeah i agree with most here... if the patient feels there is something 'wrong' with resuscitation itself, he/she has already been 'wronged'... if they think they're going to hell b/c of this... pulling the plug will send them to hell even faster. Since the act of resuscitating them has already taken place, why not let them reap the benefits of the 'wrongdoing' before they ultimately die and have to face whatever circumstances they believe they will face. If it isn't a religious conviction and simply a fear of these procedures, if you as the patient's doctor are to take this request seriously, i think you would have to have a much more thorough discussion with the patient to understand the circumstances under which they would/wouldn't want to be resuscitated... b/c i mean if they were choking on a bite of apple and someone comes to give them the heimlich maneuver... it would just be stupid to say "no, he said no resuscitation under any circumstances.... STOP what you're doing, it's unethical!!" and let the patient die instead. Someone who refuses something like that is very likely incompetent and therefore unable to make such decisions for themselves. Link to comment Share on other sites More sharing options...
Rock* Posted December 16, 2007 Report Share Posted December 16, 2007 Pulling the plug AFTER the pt has been resuscitated? That's basically murder. As an example, if you carry this to extremes, there was a real life case about a Jehovah's witness who got into an accident and needed a blood transfusion to survive. She carried a card with her stating that she didn't want blood transfusions but the physician treating her transfused anyway and she survived to successfully sue him for $20,000 afterwards because she argued that she was worse off alive and "tainted" than dead and pure. Can the physician undo his action by removing her blood and thus killing her? Probably not without being charged without murder. I think the exact same reasoning applies in this case. Link to comment Share on other sites More sharing options...
Julie Posted December 17, 2007 Report Share Posted December 17, 2007 Can the physician undo his action by removing her blood and thus killing her? Probably not without being charged without murder. Removing the donnor blood only? Wow, that would be a tricky procedure! Link to comment Share on other sites More sharing options...
sbrugby Posted January 2, 2008 Report Share Posted January 2, 2008 Likely he will make it out of the coma; it's just a matter of time until he does. So, to pull or not to pull? I think this is the biggest problem with the scenario. What does likely mean? How much time do we predict on avg? Also, what were the details of the conversation with the patient? I know this is just a hypothetical scenario, but I think as the physician I would know a lot more details than were given, and without those details, the decision really could go either way. Link to comment Share on other sites More sharing options...
rrt23 Posted January 2, 2008 Report Share Posted January 2, 2008 once a patient is placed on a ventilator you can't just "pull the plug". the patient would have to have signed a DNR order and indicated a power of attorney. that person would have to be notified and they would make the decision about whether or not to continue with the treatment as is or terminate the ventilator. things get really tricky when the patient is intubated and then you find a DNR order. it's not so easy then.... Link to comment Share on other sites More sharing options...
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