Household Words Chapter 1

Household Words * **

A weekly periodical examining a rather extraordinary clinical encounter.

Chapter 1 

We all come to Emergency Medicine with our own very individualised belief systems; a personal manifesto built up over years of practice and experience, which defines every encounter with patients that we have.

At the very heart of mine is the unceasing respect for the individual, and the acceptance that they are permitted to make their own choices, even if I don’t necessarily agree.

So it was, when a 72 year old man was purveyed to our ED by ambulance, on a priority call, because of chest pain, dizziness and bradycardia.

Seen promptly, he was of European descent, was now pain free, furnished us with a past history of controlled angina, and described a fairly typical story of an acute coronary syndrome earlier that day.

Nothing startling to find on examination (including being orientated, and quite switched on) and his ECG showed a rather impressive tri-fascicular block, without features mandating a headlong rush to the angio suite. In the setting of his episodes of symptomatic bradycardia, a discussion was initiated about getting a pacemaker put in.

At this point, the conversation became very animated….. He told me that he wanted absolutely no interventions of the sort – he would just like to be allowed to die. He wanted no drugs, no pads, no wires…. As I digested these words, and began to make some sort of laborious and self-important speech about the minimally invasive nature of the procedure and the indisputable benefits of supporting his heart rate, his heart rate drops off into the 20s, and he essentially has a brady-asystolic arrest 

What, dear reader, would you possibly do now?

Somewhat taken aback by circumstances, I (quickly) considered my options.  A man of seemingly quite sound mind, in his 70’s, with an obvious acute coronary syndrome, had just emphatically told me that he wanted no intervention that was possibly life-saving.  He had told me that at his age it was his prerogative to want to die, and he was exercising that today.  But I could not get any further history at this point, as he had lapsed into unconsciousness, as a result of his less than adequate cerebral perfusion.

So, this is what I did: I fist paced him. Rightly, or wrongly, I needed to be very clear about his competence to make a decision as to whether he could refuse treatment.  This seemed to be the most temporizing way to give him cerebral perfusion whilst we continued the discussion.  And it worked.  He had both electrical and mechanical capture, allowing him to mentate and carry on the discussion.  He volunteered that he was a card carrying member of a European euthanasia society, where he (literally) carried a signed card informing people of his will to die, he stated he had no family, or friends, left, and he felt that his meaningful life was over. He emphatically denied any attempt at suicide – today’s ischaemic event was simply a serendipitous occurrence for him.

Do imagine it though.  This was a very bizarre discussion to be having whilst I struck him forcefully and monotonously on the chest at about 70 times per minute.  Although somewhat curmudgeonly about the pugilistic nature of my treatment, he understood why I was doing it.

His myocardium drifted in and out of a sinus rhythm, during which time I desperately scrabbled for a moment of wisdom.  The drawing presence of a small crowd around me was incommodious, but simultaneously stipulated a prudent decision.

What to do?

A pacing wire is fairly innocuous in the grand scheme of interventions that we foist upon people, for a fairly impressive return.

The insertion of the wire would have been expressly against his will, as he stated it at that particular snapshot in time.

Thus, at the conclusion of this week’s episode, I ask the gentle (and not so gentle) reader, what would you have done?

  • * Household Words – This was the title of the weekly periodical (1850) edited by the literary master Charles Dickens.  It cost a tuppence, and was fanatically and eagerly awaited by its readers.. It gave a colourful reportage of the happenings of the current day, and drip-fed tiny instalments of his novels to come.  The periodical changed its name to ‘All the Year Round’ in 1859 when the incredibly successful Dickens began to publish his weekly himself.
  • ** This is in no way meant to emulate Charles Dickens himself, but is perhaps a puny homage to the great man; a philanthropist, social commentator, and colossal reformationist, who, may well have sniffed more than a passing interest in #FOAMed

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  1. says

    A competent adult has expressed his clear wishes. Possibly backed up by documentary evidence of significant thought having gone into said wishes in the form of the wallet card detailing membership of the euthanasia society. The decision would seem clear.

    The only alarm bell for me is his statement that all of his friends and family are gone. This suggests that depression stemming from loneliness may be a factor in his wish to die. Not really in the best situation to do a mental state exam though, are we?

    I don’t know what I’d do to be honest, but if someone held an EZIO drill to my head and demanded I make a decision, I’d have to say that I’d do my best to talk him out of while he’s conscious and competent, but if he loses consciousness again I’d initiate comfort care.

    Even the slightest possibility of him being depressed makes me uneasy though… Hmmm… Happy for someone to think of something that I haven’t and question my decision.

  2. Kirsty Challen says

    I think David has summed it up; the euthanasia card would refute any suggestion of it being a poorly thought-through decision, his ability to engage would suggest that even if he is depressed, it isn’t to the point of his having lost capacity (sorry UK not Aussie law here). Just because his decision isn’t the one I think I’d make, and is one that makes me feel bad and sad about lost potential, doesn’t mean it’s wrong for him. I don’t see how we can justifiably send him for pacing, however much we might want to.

  3. Liam Scott says

    (A UK perspective, but I believe the ethical / legal principles are essentially the same…) A patient is presumed to have capacity unless it can be demonstrated otherwise. If from your conversation with him he seem able to understand, retain and weigh the information to make a decision, and communicate that decision, he has capacity. You would need to be satisfied though his comprehension is appropriately detailed enough to reflect the gravity of situation and its consequences.

    That being the case, an autonomous agent with capacity is ‘allowed’ to make seemingling unwise decisions, however much we might disagree, or chose another course if we were in his position. Keep him comfortable and let nature take its course.

  4. Kath (@lanafeld) says

    Difficult situation but agree with above comments -- he’s made it very clear he doesn’t want interventions. If possible, grab a colleague to agree that it seems reasonable (possibly a bit difficult with your current pacing method).
    Could he be depressed and suicidal? Possibly. Does this possibility mean that we should “assault” him to keep him alive -- not enough in the information we have to make me think so.
    Let’s face it: we don’t let people die very well in this modern age. And generally patients and families aren’t ready for it. He clearly is.
    We let Jehovah’s witnesses refuse life-saving blood transfusions, we let parents refuse to immunise their children…

  5. Seth @mdaware says

    Craziness. I think this guy seems to know what he wants and it’s just so off-putting because we do so much that is probably futile, that dropping a wire doesn’t seem like a big deal (and, it’s probably not). I think the fistbumps are appropriate to buy some time and explain that a PPM is really not that big of a deal but the main point is: these cases throw us off our game!

  6. says

    Tend to agree with previous comments, but feel uneasy that I haven’t known him long enough to proceed to palliation so quickly in the setting of good functional status and (maybe) readily reversible pathology. A bedside US to assess his ventricle would be helpful if available, but even without this I think I’d try to obtain his permission to allow me to trial a short period of transcutaneous pacing or chronotropic infusion, to buy a little more time to explore his competence and explain in a less charged setting his treatment options. Then let him make his choice as he saw fit. Look forward to chapter 2…

  7. Franno says

    Great case, Michelle -- thankfully for me, I retain a small area of my brain for paternalistic attitudes, to carefully unwrap and roll out when the ethical going gets really tough…In a quirky paradox, resulting from the shift of our ethical paradigm from unbridled paternalism to unchecked patient autonomy, we doctors still have the opportunity to influence outcomes -- as we get to make judgments about the patient’s “competence” in an emergency.
    “Informed” consent is the key here, and we could always make the argument that we weren’t convinced that the treatment being offered (the pacing wire) was fully understood for reasons of depression/poor perfusion (or post collapse encephalopathy), hypoxia, or make something else up… The placement of a pacing wire is always temporary and in the realms of emergency life-saving treatment, and the discussion about euthanasia could be transferred to tomorrow, when he is being consented for the truly elective procedure (the PPM.) Unfortunately, a cardiologist will be having this discussion (or his poor intern, if the patient is public), and who knows where the ethical dilemma will end up then!
    Out of interest, does he turn out to have a beta blocker overdose in the end?…

  8. says

    Such valued and well considered comments, and reflects much of the decision making process that occurred rapidly, in front of an audience. This was one of the most difficult ethical dilemmas of my career. Musing over the case, after a considerable interval, swimming in the pool of hindsight, there are perhaps things I would have done differently.
    He hadn’t take a beta blocker overdose, and an ambulance had been called by a passerby, when he looked poorly out at the shops.
    As for what happened next, you will just have to wait till next week’s installment.

  9. says

    As mentioned I think he’s made a fairly clear account of his life and is to be commended to having a thought out enough life to consider truly the fact that he will (like all of us) one day be dead. Medicine in its totality is a pretty totalitarian political act in many ways (everyone knows you have to do what the doctor tells you) so it’s nice to see someone who owns their life enough to tell the docs to bugger off with your quackery and leave me alone. It takes us to have the grace and take the risk (of professional criticism) to support him.

    I would just add that I’m not sure euthanasia has much to do with this -- euthanasia usually requires a doctor and this situation requires the doctor NOT to be there

  10. Amanda says

    Difficult issue. Legally you have to initiate life-saving care BUT you also can’t offer medical interventions without consent- it’s considered battery. Ethically I’d let him pass. Legally you’d have to be pretty sure you could defend your decision if necessary.