A weekly periodical examining a rather extraordinary clinical encounter.
Well, returned reader, you recall our patient was hanging by a thread. Or a wire. Or the absence of a wire.
The comments that followed last week’s posting articulated beautifully the dilemma that presented itself. Did this man, who appeared to be of sound mind, have the right to refuse treatment for a not traditionally ‘terminal’ illness? He had obviously thought through the possibility of treatment refusal prior to this, as evidenced by his euthanasia card, although he couldn’t have predicted this particular clinical scenario that had materialized this day. The treatment, however, was reasonably simple, and could have allowed a more considered discussion to take place.
Additionally, it was a very brief period during which to come to a wise conclusion, under tremendously dramatic circumstances (percussion pacing).
As I mentioned in the comments, with the richness of time and hindsight, I may have done differently, had I my time over again.
This is what transpired at this point.
I felt very confident that this man fulfilled the criteria for consent (or the withholding of consent):
- Competent to understand
- Freely given
- Specific to treatment in question
- Comprehending the consequences of the decision
So I decided to let this man die.
I stopped fist pacing him, and stepped back.
At that moment, as had been happening in waves, his conductively blocked myocardium rallied a bit, and he maintained some sort of perfusion to his made-up mind. As I was then given somewhat more time, I gathered another consultant who was present, to be at the bedside, and informed him of the goings on. He came to the same decision as me.
At the same time, and I’m not entirely sure who made the referral, a psychiatry registrar, and then his consultant came along. In the interests of brevity, they decided that our patient was not competent to refuse treatment because he wanted to die.
Please forgive my brash mixing of literary references here, but this seemed to be a classic Catch 22 moment. If you said that you wanted to die, then you must be depressed, and therefore do not have the capacity to make informed decisions, certainly ones with such grave consequences*.
He was whipped off to the cardiology unit, and a pacing wire was placed.
There is no right or wrong in this situation. Only opinion. The evidence is based upon the opinions of others, including those versed and trained in law.
I’ve included some references, from the UK and the US. Australian literature echoes the same.
In essence the more dire the consequences of the decision being made, the greater the onus is on the patient to demonstrate their capacity to understand and make informed choices.
You could certainly argue in this case that I was unable to establish that true informed consent could have been given, in such a short time, in a condition that unquestionably impaired cerebral perfusion.
As for depression retarding the ability to make a decision regarding refusing treatment, it appears as though, in the absence of severe disease, or psychotic features, that one is not rendered unable to make such cognitive choices. Those features were certainly not evident in our short therapeutic relationship.
The euthanasia debate is a whole other complex issue, which the economy of this chapter shall disallow, but if a person had the ability to weigh up the consequences of joining a euthanasia society whilst well and optimally cerebrally perfused, then surely this should be sustained into a situation such as this.
BUT, faithful reader, the story is not over yet…
* The Catch-22, the paradoxical logic underpinning Joseph Heller’s triumph, states that if a pilot requests an assessment to prove that he is not mentally fit to fly combat duty, then he must be sane, by that act.
“You mean there’s a catch?”
“Sure there’s a catch”, Doc Daneeka replied. “Catch-22. Anyone who wants to get out of combat duty isn’t really crazy.”
** Both the wonderful @broomedocs and @rfdsdoc would not forgive me if I didn’t make mention of Albert Camus’s ‘The Myth of Sisyphus’, an essay, published in 1942, which commences with the words “There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy”. I also recommend the wonderful ‘Sense of an Ending’ by Julian Barnes which won the 2011 Man Booker prize, and touches on this.
- Rudnick A . Depression and competence to refuse psychiatric treatment. J Med Ethics 2002;28:151-155 [abstract]
- Paul S. Appelbaum, M.D. Assessment of patient’s competence to consent to treatment N Engl J Med 2007; 357:1834-1840 [full text]
- Legal and ethical aspects refusing medical treatment after suicide MJA [Text]
- The Myth of Sisyphus by Albert Camus