*College of Pharmacy and Emergency Medical Services Academy (adjunct), ... and Arizona Bioethics Program, University of Arizona College of Medicine, ...
ELSEVIER
PI1 s0736-4679(97)00157-1
EtMcs of Emergency e
THE CRITICAL
PATIENT
WHO REFUSES
Robert B. Pak?Ier,
PhD,*
TREA=MENT:
and Kenneth
AN ET
V. iSerSOn,
MD,
MeAt
*College of Pharmacy and Emergency Medical Services Academy (adjunct), University of New Mexico, Albuquerque. New Mexico and tDepartment of Surgery and Arizona Bioethics Program, University of Arizona College of Medicine, Tucson. Arizona Reprint Address: Kenneth V. Iserson, MD, MBA, Department of Surgery, University of Arizona College of Medicine, 1% f North Campbell Avenue, Box 245057, Tucson, AZ 85718
U Abstract-In clinical practice, emergency physicians must often make decisions in their patients’ best interests when the patients are unable to do so themselves. The usual requirement for informed consent stems from recognizing individuals’ autonomy and their right to make decisions affecting their bodies. Abandoning a requirement for consent is an emergency exception to the ethical and legal principles and comes into play only when a person lacks decision-making capacity. In some instances, it may be unclear whether a patient has this capacity, confounding the physician’s management decisions. How should emergency physicians assessa patient’s decision-making capacity? When may they ethically and legally override a patient’s expressed desire for treatment or nontreatment? These issues are discussed in the context of an actual case. 0 1997 Elsevier Science Inc.
to do this. If a patient is unknown to the clinician, as is often the case in emergency medicine, and if no readily interpretable advance directive is available, the clinician must use a best-interest standard, that is. doing what a reasonable person would want done under the same circumstances. In these instances, emergency physicians must make treatment decisions based solely upon medical information without regard to the patient’s actual wishes. This is done under an emergency exception to the ethical and legal principles requiriag informed consent. It comes into play when a patient is too seriously ill or injured to understand and give an informed consent to medically necessary procedures in situations when a reasonable person would elect to have such measures instigated. Realistically, even a seemingly superficial or routine case may have significant ethical issues present. Unfortunately, many emergency physicians often fail to realize an ethical conflict exists. This lack of recognition of the issue precludes the next step in the management of the case. that is, the formation of an appropriate action plan.
U Keywords-ethics; emergency medicine; autonomy; informed consent; benetlcence; emergency (presumed) consent
INTRODUCTION In clinical practice, emergency physicians must often make decisions in their patients’ best interests when the patients are unable to do so themselves. Clinicians are encouraged to use the patient’s values or a surrogate’s substituted judgment to make significant decisions. However, in critical situations there is often insufficient time
Ethics is coordinated by Kenneth Iserson,
MD,
MBA,
PATIENT
There are two general types of consent: implied and informed. Both are operative in the emergency setting. Implied consent (more properly termed presumed con-
of the Arizona Bioethics Programs at the University of Arizona.
Tucson, Arizona RECEIVED: ACCEPTED:
CONSENT
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19 August 1996; FINAL SUBMISSION RECEIVED: 28 January 1997: 18 February 1997 729
730 Table 1. Components of Informed Consent The patient has decision-making capacity The patient is given all of the pertinent facts regarding risks and benefits of a particular procedure The patient understands all of this information The patient voluntarily agrees to undergo the procedure
sent) covers lifesaving procedures that any reasonable person would normally want done, if necessary.Implied consent can be operative in a patient who retains decision-making capacity (as when an arm is held out in order to donate blood), or in a patient without this capacity (such as the individual who is brought in unconscious with a gunshot wound to the chest). The usual requirement for informed consent stems from recognizing individuals’ autonomy and their right to make decisions affecting their own bodies (1). Informed consent assumesthat a patient with decisionmaking capacity is given all the pertinent facts regarding the risks and benefits of a particular procedure, understands them, and voluntarily agreesto undergo the procedure (Table 1). It is in this matter that confusion often reigns. Does the patient have the capacity to understand? Is this capacity questioned only if there is refusal of appropriate medical care?Furthermore, what procedures require informed, as opposedto implied, consent (2)? Despite serious illness or injury, emergency department (ED) patients generally want to participate in their care decisions (3). When patients express their wishes, they may do so with varying degrees of thought and clarity. It is common in the ED, for example, to encounter intoxicated patients who refuse to have their lacerations sutured. The physician’s judgment about the possible consequencesof allowing such patients to leave the ED without standard care often comes into play. In some instances, it is necessaryfor the emergency physician to initiate possible lifesaving measureseven when the patient refuses. In these occurrences,the argument is generally made that a reasonable and prudent person would want to have his or her life saved. However, the validity of the converse statement, that an individual who does not wish to live is not reasonable and prudent, is the subject of some debate.For example, in more serious cases, like closed head injuries, much more care must be exercisedon the part of the physician. Otherwise, a seriously injured patient may be allowed to leave. In these cases,even though the physician believes it may be to the patient’s detriment, the patient may refuse care. The following dilemma then surfaces: At what point is a patient no longer capable of making a decision regarding his or her medical treatment? It is up to the physician to decide if the patient has the necessarydecision-making capacity or whether to invoke
R. B. Palmer and K. V. lserson
the emergency exception in the absence of previous patient directives or a surrogate decision maker. Consider the following representativecase.
CASE REPORT
The patient, a moderately obese 42-year-old male mechanic and a heavy smoker, presentedto a rural hospital ED complaining of severe chest pain. With no prior history, the patient was awakenedfrom sleepby crushing (9 on a pain severity scale of 1 to 10) substemal chest pain and dyspnea.He drove himself about one mile to his local hospital’s ED where a 1Zlead electrocardiogram demonstrateda large inferior myocardial infarction. He was started on oxygen and given an aspirin. Scarring from a prior motorcycle accident precluded peripheral intravenous accessso a subclavian line was started. He was then given meperidine (since he was allergic to morphine), bolused with heparin, and a nitroglycerin infusion was started at 20 pg/min. His chest pain was poorly controlled and remained at 8/10 pain severity. The emergencyphysician discussedthe situation with the patient, his family physician, and a consulting cardiologist at a referral hospital. The cardiologist recommended surgical intervention over thrombolytic therapy based on the difficulty in obtaining intravenous access and the presenceof a central line. The emergency physician then suggestedthat the patient be transferredto the referral facility as it has cardiac catheterization and cardiothoracic surgery capabilities. When the patient, still in intense pain, was presentedwith the appropriate transfer consent forms, he stated, “I’ll sign anything. Do whatever you need to do, just please don’t let me die.” The patient signed the forms, which also included a consent for cardiac catheterization. The patient was then transferred via mobile critical care ground ambulance to the referral hospital 45 min away. Just prior to arrival, he became agitated and attempted to remove his subclavian line. He insisted that he be taken home and not to the catheterization laboratory. At that point, the transport team administered another 2.5 mg of diazepam and 50 mg of meperidine intravenously (in addition to the 10 mg of diazepamand 250 mg of meperidine he had already received). The nitroglycerin drip was now running at 60 pg/min, with the blood pressure hovering around 94/40 torr and the heart rate at 100 beats/minute.On 15 liters of oxygen by nonrebreathermask, the oxygen saturation was 97% but quickly dropped to 89% if the supplementaloxygen was removed. Upon arrival at the second ED, the attending emergency physician reviewed the record and noted that the patient remained sedated.Despite the transport team’s
Critical Patient Refuses Treatment
i31
history that the patient had changed his mind and was now adamantly refusing catheterization, he was transferred to the catheterization laboratory because of the presence of the signed consent form. In the laboratory, the patient was moved onto the catheterization table. He refused to lie still and again became belligerent and combative, insisting he did not want the procedure performed. The attending cardiologist explained that failing to have the procedure performed would likely result in death. The patient was still insistent that the procedure not be performed. When questioned, he could not give a reason for his refusal and, in fact, refused to converse with any of the clinicians.
DECISION-MAKING
CAPACITY
Clinicians’ decisions about whether patients may make their own health treatment decisions do not rest with the patient’s apparent inebriation, intelligence, or degree of distress. Rather, these decisions rest with whether the patient retains decision-making capacity. This capacity varies with each decision; the presumption is always that patients have this capacity unless they are delirious or comatose. However, even profoundly mentally retarded patients have some decision-making capacity. Though usually not about their medical treatment, they may still decide what clothes to wear or what food to eat. Many times, when providing a patient the medical information necessary to obtain informed consent, the physician must do a balancing act. That is, the physician must avoid psychological or informational manipulation or using the position of authority to coerce the patient into a pseudo-voluntary acceptance of the proffered care (4). An individual’s decision-making capacity varies with the decision that must be made. In the context of medical treatment decisions, higher standards exist for those decisions with more serious consequences. In some cases, more complex decisions also require a higher level of decisional capacity, although this is not usually so. An example of the difference between the two is that withdrawing ventilator support in a dying patient is a simple concept with irrevocable outcomes. In contrast. doing a multilevel wound closure on the leg may be complex but with many fewer serious consequences. How then should decision-making capacity be determined?
Table 2. Components of Deoision-making
Capacity (5) ..---_____.-
Knowledge of the options Awareness of consequences of each option Appreciation of personal costs and benefits of options in relation to relatively stable values and preferences (When ascertaining this, ask the patient why they made a specific choice.) _I_- .._-. -._---.-
emergency physicians need to employ rhis skill daily both for patients in the ED and for those with whom they consult via the emergency medical service radio for patient refusals or demands. How can the physician quickly determine whether a patient has decision-making capacity for a particular decision’? To have adequate capacity to make a specific decision, an individual must demonstrate that he or she understands the options, the consequences of acting on the various options, and the costs and benefits of these consequences by relating them to his or her relatively stable framework of personal values and prioriries 17’:~ ble 2). Disagreement with a physician’s recommendation is not by itself grounds for determining that the patient is incapable of making a decision. In fact, even refusal of lifesaving medical care may not prove a person incapable of making valid decisions if that refusal is made based on long-held values. For example. Jehovah’s Witness patients refuse blood transfusions. In the presented patient’s case, the cardiologist explained the risks and benefits of cardiac catheterization. However, there was no indication that the patient assimilated the information. If he was not capable of doing so at the time, he lacked decision-making capacity. The option of reversing the narcotic and benzodiazepine sedation might restore his decision-making capacity but might also endanger his life. Furthermore, the patient would not speak with the cardiologist and other clinicians in the catheterization laboratory. It has been documented that a patient who cannot express his or her reasons for refusal of care and will not converse with clinicians is considered IO lack decision-making capacity (6) The patient’s silence further accentuates that he is unable to relate iris decision to a stable and long-held
framework
of values.
THE DILEMMA DETERMINING DECISION-MAKING CAPACITY The assessment of a patient’s decision-making capacity is a basic clinical skill for emergency physicians. Most
At the time the patient in the presented case consented to the transfer for catheterization, three possible reasons why his consent was not binding exist: Ii he was hypoperfused and hypoxic as a direct result of the acute myocardial infarction: 2) he was experiencing significant
R. El. Palmer and K. V. lserson
732 pain and was no doubt terrified; and 3) he had received narcotics and benzodiazepines. Upon the patient’s arrival at the tertiary-care ED, the emergency physician was presentedwith a difficult situation. The transport team’s history clearly demonstrated that the patient was emphatically refusing an emergent and potentially lifesaving treatment to which he had initially consented.Yet, he had received large doses of both benzodiazepines and narcotics. At this point, the emergency physician had to decide if both criteria for overriding a patient’s wishes were present.First, was the patient’s condition serious enough that the failure to perform the cardiac catheterization (and subsequentangioplasty, etc.) would likely result in death or severe morbidity? Second,was the patient competentto partake in this decision in light of his underlying condition and medication use at the first hospital, in the transport unit, or at the referral hospital? As in many such situations, the emergency physician had little information, most of it second-or third-hand, to rely on in making the decision. OPTIONS FOR ACTION The emergency physician and the cardiologist had four available options: 1) administer naloxone and flumazenil to eliminate the effects of the meperidine and diazepam on the patient; 2) chemically restrain (sedate)the patient and go ahead with the intended procedure(s); 3) admit the patient to the critical care unit (CCU), discuss the procedure with him and allow him time to think it over; and 4) allow the patient to go home as he requested. The fourth option would have, almost invariably, resulted in the worst outcome. The patient was a very sick man and allowing him to leave the hospital would have almost certainly resulted in his demise. The first option was not much more palatable. Administering antagonists to the analgesicsand anxiolytics to possibly obtain consent for a procedure is below any acceptablestandardof care in this situation. Pain control was difficult to achieve and eliminating this analgesia may have caused additional cardiac damage,untoward pharmacological effects (e.g. seizuresfrom the flumazenil), and an increasein the pain until the antagonists wore off. Therefore, two options remained: (1) admit the patient to the CCU and allow him to think over the catheterization; and (2) based on the signed consent, chemically restrain the patient and go aheadwith the procedure. If it was decided to admit the patient to the CCU and allow him to consider his options and the consequencesof his decisions, additional damage to his heart might occur that would adversely alter his life, provided he survived. Who should determine whether this is an acceptablerisk for the patient? The questions the emergency physician
and cardiologist posed were: Could the patient’s autonomy be completely disregarded?Were they, as physicians, acting paternalistically if they disregardedhis current stated wishes to stop medical interventions? What would make it acceptablefor the patient to reverse his initial decision? PATERNALISM Physician paternalism (now often called parentalism in recognition that all health care providers may act in the same manner) is usually contrasted with patient autonomy. This physician behavior restricts patient “autonomy in an effort to benefit, or reduce harm to, the person whose autonomy is limited” (7). This means that the “physician makes the crucial decisions concerning patient care for the patient’s benefit (as the physician sees it)” (8). The paternalistic physician will act contrary to a patient’s informed decisions when the patient retains decision-making capacity, because the physician believes it is the right thing to do. If the patient lacks decision-making capacity and no surrogate decisionmaker is present, the physician intervenes basedon professional knowledge and the patient’s best interest. This represents an expression of the physician’s duty and responsibility rather than simple paternalism. Physicians, especially emergencyphysicians, must often act without patient direction in order to try to reduce morbidity and mortality. LEGAL SITUATION Contemporary physicians often give greater consideration to the legal ramifications than the ethical implications of their actions. Yet, the two are frequently related. The question emergencyphysicians should ask themselves is the following: If I should end up on the witness stand,can I say that I did what I thought was best for my patient, who did not provide competent direction? Conversely, would I rather say that I did what I thought the law required, even though it might cause my patient to have an adverseoutcome?Actually, the legal and ethical requirements are parallel. Both direct physicians to act in their patients’ best interests unless they have competent direction from the patient or a bona fide surrogate decision-maker. AN ETHICAL DECISION Weighing the potential benefits and detriments of a treatment decision is part of everyday clinical practice. Eth-
Critical Patient Refuses Treatment
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ical dilemmas frequently require choices between uncomfortable options. Clinicians often act in gray areas with competing goods or evils and no obvious right course of action initially evident. These types of cases are not unusual and emergency physicians should not waiver over potential accusations of paternalism. This is not paternalism (acting in opposition to a patient’s informed decision because the clinician feels the action is in the patient’s best interests). In cases similar to the presented patient’s, emergency physicians must assessthe patient’s condition, the severity of the clinical situation, and the patient’s decisionmaking capacity. While it is standard practice to obtain informed consent for many invasive procedures, a patient’s condition may limit the information that can be effectively presented. Furthermore, no one knows the effects that the stress and anxiety from illnesses or injuries. any medication or nonmedication drugs, or being in
the ED may have on a patient’s decisions. Only clinicians are qualified to assess the severity of a patient’s clinical situation including the potential adverse outcomes. They are the experts and cannot defer this assessment to their patients. Finally, however, the physician’s assessment of the patient’s current condition and of the severity of potential outcomes converge. This point is where the clinician must determine the patient’s decision-making capacity. In the presence of potentially deleterious outcomes. when patients cannot comprehend the elements of risk and benefit essential to an informed consent or when they cannot relate a decision to a stable value system, and when they have no immediate surrogate decision-maker. the physician must proceed with what would be normally considered the standard of care. In the case presented here, the physician should sedate the patient and proceed with the angiography.
REFERENCES I. Brock DW. Informed participation in decisions. In: Iserson KV. Sanders AB, Mathieu D. eds. Ethics in emergency medicine. 2nd ed. Tucson. AZ: Galen Press, 1995:56-61. 7. lscrson KV. Bioethics. In Rosen P, Barkin RM. Emergency medicine: concepts and clinical practice, 4th ed. St. Louis: CV Mosby [in press./. 3. Davis MA. Hsu J, Hoffman JR. Impact of patient acuity on patient preference for medical decision making autonomy and information. Acad Emerg Med 1996;3:491 Abstract. 4. Beauchamp IL. Uncertain diagnosis and the uncooperative patient. In Iserson KV, Sanders AB, Mathieu D, eds. Ethics in
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emergency medicine. 2nd ed. Tucson. AZ: Galsn &es>: 1995:76-m 80. Iserson KV, Sanders AB, Mathieu D. Ethics in emergency medicine, 2nd ed. Tucson. AZ Galen Press; 1995:.5-h. Katz J. The silent world of doctor and patient. New York: The Free Press; 1984:156-63. Kennedy Institute of Ethics. Bioethics thesaurus. Washington, DC: Georgetown University, 1993:33. Landesman BM. Physicians’ attitudes toward patients. In: lserson KV. Sanders AB, Mathieu, D. eds. Ethics in emergency medicine. 2nd ed. Tucson, AZ: Galen Preys: 1995:350--7
