Household Words Chapter 2

Household Words

A weekly periodical examining a rather extraordinary clinical encounter.

Chapter 2

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
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  1. says

    …I presume they (the psychs) also detained him (or scheduled, or equivalent local term) for treatment ‘in best interests’

    What did the patient say to all this?

    Anyhow, I;m impressed by the psychs. Usually can’t get them to see a patient until ‘medically cleared’

    Who referred him to the psychs? And how did the face-off between two ED consultants and the psych pan out?

    • says

      Tim -- it was the second ED consultant who made the referral to the psych team. There was no face-off; difficult enough in areas that are black and white, let alone this 50 shades of grey (to quote an anti-literary reference)

  2. Minh Le Cong says

    L’etranger is my favourite Camus novel. I am pretty sure he was depressed. Camus.
    This sounds like a case over in UK where hospital docs had to decide whether to treat or not treat a woman presenting with a fatal overdose and express wishes made on a letter

    but intentional act of suicide vs letting nature take its course , like not treating a peri ACS complication. thats a different can of worms.

    • says

      Camus was not depressed -- he was way too productive! He suffered TB -staring slow consumptive death in the face for years, then dying in an MVA -- was it suicide? Aside from Le mythe de sysiphe check out la Chute ( the fall) and A Happy death -- great illustrations of the perspective of death from a sick fellow..

      In the case at hand, I wonder if we have grown an over important sense of our role in the care of patients sometimes.. Our interventions treat disease, but often do little to improve quality or quantity of life… What happens to this guy on discharge, would clutching a magnet to his chest be seen as a suicidal act if it disabled his PPM and left him in a low output state where Drs were not there to witness his demise?

      Why do we approach cancerous and cardiac disease so differently? we treat some diseases more aggressively because we can, we have interventions that “work” and we apply them often without much thought or consent from the patient.

      Consider this scenario: 80 yo guy sees a Cardiologist in clinic for sick sinus, heart block, dilated cardiomyopathy etc. they discuss treatment options and the patient declines intervention as he has other comorbidities ( bad COPD and slow growing prostate Ca) -- he has spent a lot of time in hospital and is prepared to take what comes.
      Would the average Cardiologist ask for a Psych consult to determine competence? I think not.
      Sure Michelle’s case has more drama and immediacy, but the ethical principles are similar?

      How the hell did the Psych determine incompetence in a brief, ED consult. At best they are making a culturally-based judgement call. Sure a pragmatist might say: better alive and arguing, than dead with principles intact. But an uber-pragmatist, like me, would say -- what is to stop this guy walking out of hospital in a week after successful cure and swinging a rope over a branch. If he wants to die, he will find a way…. should we assign him a 24/7 social worker to keep him away from sharp objects? This is the logical conclusion to the current state of play!

      Read Chuck Pahlunuik’s hilarious novel Survivor for a more artistic exploration of this issue!

  3. Katrin Hruska says

    Great post! I can’t see that Swedish law would have permitted me to treat him against his will. If he were threatening to jump out the window -- yes, but he is just refusing treatment. Jehova’s witnesses refuse blood transfusions, but you don’t have to rule out depression in them, uncless there is clear suspicion, do you?
    It’s getting extremely hard to die decently and wirelessly in our cultures.

  4. Aaron Andersen says

    Tough case, great presentation. One option not mentioned is to transcutaneously pace him; although painful, it’s much less invasive than dropping a wire and would fix the perfusion problem so you could talk. I had a somewhat similar case with a ruptured AAA, where I was about to tube the patient due to progressive shock, and he clearly said ‘no’. At the bedside, all I could do was respect a man who, based on my gut and gestalt, as well as monitors that showed reasonable O2 sats and measurable pressure, was very clear about his wishes. He asked to see his family, was able to, and passed in the trauma bay with a daughter at his side. It still sticks out as one of the more dignified deaths I’ve ever seen, and I’m proud of it. The consultant was there, and did not interfere, as she also witnessed the patient’s statements, so I didn’t have to deal with that. Dr. Leap has also expressed this conundrum when asking us to ‘chart the truth’; I think we see enough of these situations that we are uniquely positioned to respect patient wishes for end of life care. I’ve been on the other end, when I had a 90-plus sepsis patient who said ‘please help me’, so I did, even if I thought the chance of a good outcome was minimal. If we’re going to allow patients to be involved in their care, it shouldn’t stop as soon as there’s a bad outcome looming.

  5. Keeweedoc says

    Hi Michelle, You summarise this very well but in the heat of the moment it is always very different.
    I have to say it is an interesting contrast to the discussion a wee while ago on twitter about restraining a patient to give them NAC. I would suggest that that patient much more likely to be lacking capacity than your dear old man.
    Interesting that psych just turned up?!
    Have to say im getting that “bad gut” feeling about the whole thing. amazed they said he didnt have capacity, actually gobsmacked. how did he take it/respond? (thinking might be part 3)

  6. Minh Le Cong says

    this is a very slippery slope. When things are clearly futile, it is an easy decision. but what if its clearly treatable, like this case and pacemaker?
    what if its a 16 yo with anorexia nervosa presenting with electrolyte related arrest? And she has a DNR tatoo across her chest?
    Jehovahs witnesses refuse life saving therapy on occasion…is that a form of suicide?
    Suicidality is episodic, coming in waves and its not uncommon folks who attempt suicide feel better and not suicidal the next day or so. so what this man says right now, during the stress of percussive pacing, may in all likelihood change the next day…does that mean we do not give him the opportunity to change his mind?

    in fact what the psychiatrist advised, is not all that unreasonable.

    • MH says

      I think in this case he is unlikely to be one to change his mind… the card in his wallet would seem to indicate he has thought it through fairly carefully. RE: slippery slopes, I think we must be wary of using this as an argument and each case should be considered on its merits, not continuing and not placing a wire for this patient does not automatically mean we would not resuscitate the 16 yo. This reminded me of an except from a philosophy text; “The first precarious step onto a slippery slope often precipitates a downward plunge towards a forest of other verbal perils, where there is a clatter of falling dominoes, snowballs grow to monstrous proportions, floodgates are flung wide open, and every iceberg has hidden depths.”

  7. franno says

    Sure, we may have assaulted him, but now I believe there is a more level “ethical battlefield”. Doctors making assessments about “capacity” and informed consent can take their time, and the patient can try a number of different ways to get his point across regarding the end of his own life. The discussion regarding withdrawal of life-sustaining treatments (i.e.. a pacing wire) and refusal of permanent pacing can occur in the cold light of day, without any question surrounding brain perfusion or mental capacity (well, that can’t be more readily answered, anyway.) He might even get to enjoy a last (public hospital) meal, to really contextualise his end of life decisions…Euthanasia has nothing to do with this ethical dilemma, as i see no painful/uncomfortable decline from an untreatable condition here -- calcific conducting system disease is so easily treatable, and otherwise painless.
    Taking the pacing wire out, without a PPM to follow is either suicide, or craziness (Catch-22!)
    However, I would now have no problem with the patient now progressing to demonstrating competence, and then to refuse life-saving treatment, and eventually having his wishes (more comfortably) respected. I think the key is doing all of this “in good faith” -- which mandates a struggle with the ethics, and the investment of time and effort.

    • says

      Should competence be the default position, should we be required to prove incompetence prior to taking action against a patients expressed wishes?

  8. Ed Archer says

    As stated above, this case has nothing to do with euthanasia ( “a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering”), although the presence of the card in the pocket especially in the heat of the moment must have confused things greatly. I’d argue that a DNR tattoo is never going to be valid in a resuscitation -- it’s one thing to have a mind-set when you get the tattoo (“countersigned” by a person making money out of the “art”) but what about at the time of resuscitation? The analogy with Jehovahs Witnesses is also not valid -- as with that belief comes documented, long-held and ingrained beliefs backed by a community of non-impaired individuals. And it has long been predetermined that the JW doesn’t want a specific therapy -- blood.
    To me, what is key here is that this man has a condition that could potentially impair his judgement -- poor brain perfusion. In the light of that it would be incredibly difficult to make an irrevocable decision before being sure that it is truly the patients wishes. It would have been quite different if he had had a relative or close friend by his side to confirm that this was consistent with his wishes.
    No such luxuries were afforded in the very short space of time in this case.
    We have become very good at keeping people alive at all costs but have lost the humanistic element to allow people to die with comfort and dignity at a time of their choosing. Having said that, this man unwittingly (perhaps) put himself into an environment where the pressures of time and lack of patient familiarity urge us to commit rather than omit action. He has given away the power over his own destiny.
    I’d argue that the right thing was done in this case, but would it be reasonable to warn him (PPM working and depression excluded) about the grave dangers of putting a magnet over the machine? Destiny back in his hands.
    Great discussion Michelle, I’m sure you are grinning like the Cheshire Cat.

  9. Ed Archer says

    This might get a bit circular, but what I’d like to know is -- did you have to restrain this man to get the wire in?
    Did he ever physically refuse treatment or did he perhaps use the time to weigh up his options and allow things to happen around and to him?

  10. Duncan says

    Does he have capacity? Yes.
    Does he have competence? Yes.
    Does he have the right to refuse treatment? Yes.
    Is his decision the right one? Depends on who answers that question.
    Is his decision the right one for him? Yes.
    Could that decision change in other circumstances? Yes. Like after life saving treatment.

    The treating doctor (rightly or wrongly) gets to assess competence and capacity. Although the default is to assume they are both there, it gets harder when the condition being treated could feasibly compromise them.

    Did he *want* to die? That’s very different from not wanting life-sustaining measures.

    What psychiatric treatment was offered? Regulation under the mental health act **does not allow for treatment of physical illness -- only psychiatric** (not sure if this varies from state to state).

    A patient with a headache sees a psychiatrist, a neurosurgeon, a neurologist and a GP. He is diagnosed with, in turn, depression, a brain tumour, a migraine and a tension headache. Show this patient to a psychiatrist and you will get a psychiatric diagnosis.

    I think this man has been assaulted. Even if he changed his mind afterwards, and even if the intentions were good.

  11. says

    Thank you all for the impassioned comments -- just a few follow up comments before progressing on to chapter 3.
    Aaron -- I did consider transcutaneous pacing, but it also seemed to transgress his clearly stated wishes of intervention. Well done on your case.
    Franno and Ed, you are right about the distinction between this and euthanasia, but there are many crossovers in the principles.
    Ed, well expressed. Although you are wrong about one thing -- there was no grinning, it was one of the saddest cases I have faced, and stayed with me for a long time. Mind you -- expect to be ferociously tested about this next week :-)
    Duncan -- excellent points, and similarly Mackenzie -- I think this is the side of the ledger on which I initially ended up. He had very clearly thought about issues of medical intervention, and death, and had the clarity of thought to bring out the card and show me in this circumstance.
    In defence of our Psychiatrists, they provide an excellent service to the ED, which may reflect the screaming necessity to have them around so much.

    And thus, with a heavy heart, on to chapter 3…

  12. Amanda says

    The wish to die implies depression? Not necessarily. The question is, can people rationally wish to die without a psychiatric illness? And the answer is of course yes. I recognise that suicidal ideation can be a symptom of depression- but deciding that a person must be depressed because of this, without any other psychiatric assessment, is absurd.