The BioEthics Cafe -- Essays from the Edge of Paradise

The BioEthics Cafe -- Essays from the Edge of Paradise


The threat or pressure placed on physicians at the time of making a life and death decision is even more influenced by the threat of litigation. In a time of extreme stress, physicians are required to make decisions that are in the best interest of the patient and that also agree with the patient's wishes. In terms of "End of life" decisions, often every minute counts. And while the physician may have a state recognized "do not resuscitate" (DNR) order that documents the patient's wishes, there can be many members of the patient's family who surface at the 11th hour with conflicting views about what the patient wants in that situation.
For example, there was a patient in my hospital who came into the emergency room unconscious and in septic shock. She was a 76 year-old, widowed nursing home patient with four children. Her oldest daughter was her medical power of attorney. She had also signed an Advanced Directive six months prior, that stated her life not be sustained by any artificial means. She had specifically documented no intubations or CPR.
It was determined by the attending physician that this woman was in respiratory distress and needed to be intubated to prolong her life. The power of attorney, along with two other siblings reiterated the patient's wishes of no intubation. However, the physician received a phone call from the fourth sibling, her son from Washington D.C., who stated "Everything be done". The wishes of the patient and the rest of the family were not enough to convince the son to change his mind. He threatened the physician with a lawsuit.
The emergency room physician intubated the patient contrary to her wishes. While in the AICU, the intensivist would not extubate the patient because of the son's wishes despite her advanced directive. She subsequently expired 4 days later of cardiac arrest but not before a prolonged megacode to keep her alive.
Because both these physicians felt legal pressure, they did not honor the patient's Advanced Directive. They were swayed from allowing the patient to naturally pass, as per her wishes, to avoid litigation.
Unfortunately, this is becoming a trend where the DNR paperwork that comes in with a patient is not worth the paper on which it is written. While it used to be a guide that the physcian could use in directing treatment, now the patient's wishes seem to be secondary to potential legal threat. Personally, I am yet to see a physician stand up to this threat and withhold treatment in accordance with the patient's wishes. In the future it will require the hospitals and the legislature to strongly support physicians so they can provide or withhold medical care as originally intended by the patient.