A elderly man was found unconscious at home having taken an overdose of prescription medication. This event may have been precipitated by a recent bereavement and worsening of his preexisting depression for which he had recently been reviewed by psychiatric services and commenced on an SNRI. He left a note at the scene of the suicide attempt, clearly stating that he intended to take his own life and did not wish to be resuscitated in the event of being found alive. He was discovered in his home by a relative who had been growing increasingly concerned as to his welfare, having not spoken to him for several days. On arrival in ED his Glasgow coma score (GCS) was 3/15. He was known to be taking venlafaxine for depression and amitriptyline for chronic back pain, and empty packets of each drug were found at his home.
He was intubated and transferred to the intensive care unit. Supportive care was provided including vasopressors (noradrenaline) for hypotension, electrolyte correction and ventilatory support. Plain chest radiograph showed a probable aspiration pneumonitis affecting the right upper and middle lobe. He was hypoxic with a high Fi 02 requirement and needed high levels of PEEP to maintain adequate oxygenation. His conscious level fluctuated over several days and he became increasingly agitated and exhibited signs of distress. At this stage it was not clear if he was orientated in time, place or person. He underwent percutaneous tracheostomy to facilitate weaning and reduce sedation requirements.
We were then able to wean him from sedation by day 11 of his admission. The patient’s ventilatory requirements were still high requiring mean airway pressures of 30 cmH2O, PEEP of 10 cmH2O, and an inspired oxygen concentration of 60%. At this stage he indicated to the ITU team that he did not wish treatment to be continued. We found him to be fully orientated in terms of time and place and he was aware of the preceding events and his intentional overdose. It was clearly explained to him that if treatment were discontinued he would die. He indicated to us that he had no intention of changing his mind.
We referred him to the liaison psychiatrist for the hospital who independently assessed and found him to be competent and able to fully understand the implications of such a decision, i.e. his likely death from respiratory failure. The psychiatrist also found him to be depressed but noted that this did not interfere with his competence and ability to give or withhold his consent. With his consent, his family were informed of this development. They had been agonizing for some time over whether they had made the right decision to call emergency services when they first found him. They attempted to dissuade him but his resolve was unshakeable. Invasive ventilation was withdrawn on the morning of his 15th day of ITU as per his wishes. Diamorphine was administered to reduce symptoms of respiratory distress. He died of hypoxia later that day. Cause of death was recorded as aspiration pneumonia.
Describe the ethical and legal framework utilised in the management of this patient.
David Hepburn
A number of ethical issues are raised by this case. The family were filled with conflicted feelings of guilt about calling the emergency services to this gentleman’s aid after finding the suicide note at the scene. On witnessing his protracted ITU stay and the distress and discomfort evident in the early stages of his admission, they questioned whether this was the correct course of action. We reassured them that they had done exactly the right thing. A suicide note is not a recognized form of advance directive, and finding him alive but not acting to save him would make them at the very least guilty of assisting suicide, if not manslaughter. Assisted suicide is currently illegal under the terms of the Suicide Act (1961) and is punishable by up to 14 years’ imprisonment. (1)
Once lifesaving treatment had been commenced, withdrawal or cessation could happen only on grounds of futility (in terms of failure to respond to this treatment) when agreed by treating medical team; or as in this case patient indication that they do not wish to continue being treated.
Treatment on ITU is based on the four tenets of medical ethics, specifically beneficence, non maleficence, justice and autonomy.
Beneficence means that treatment should only be given if it will likely benefit the patient. By this rationale, treatment that is failing to be of benefit should be withdrawn. On the other hand, non-maleficence is the doctrine of “first do no harm”; that treatment should not be embarked upon if harmful effects outweigh the benefits. This doctrine is sometimes endangered in ICM when overly heroic therapies are employed at all costs. Justice is the right to be treated equally, and the right to equal access to treatment. Autonomy outweighs all of the other tenets, and it was patient autonomy and maintaining this autonomy that affected this case. Autonomy allows a patient to refuse treatment even if doing so would endanger their lives. Individuals have the right to make decisions regarding their own health, even if these decisions may be seen as foolish or dangerous by those caring for them. Establishment of an individual’s right to exercise their autonomy is through assessment of capacity. (2) Capacity in the UK is governed by the Mental Capacity Act of 2005. It identifies five main points:
- Every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise.
- A person must be given all practicable help before anyone treats them as not being able to make their own decisions.
- Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision.
- Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests.
- Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms
In the case of our patient he was found to be able to understand and retain information given to him, he was oriented in terms of time, place and person and most importantly he understood the implications of his decision to refuse treatment. The fact that he was depressed is not an automatic bar to having capacity (3). Depression can distort normal thought processes and potentially disrupt capacity, particularly if psychotic features are present. However, if decisions made are done so in a manner which is consistent with previous decisions; and the patient demonstrates the ability to retain, weigh up and fully understand the ramifications of these actions then capacity can be retained despite depressive symptoms. In cases such as this a careful multidisciplinary approach with early input from psychiatric services is paramount.
Lessons Learnt
While the outcome in this case was the death of the patient, it should be considered an ethical success in that the patient’s autonomy and right of decision making was maintained. As clinicians we may find it difficult to accept when patients make decisions which do not appear to be in their “best interests” but we must operate within the framework of medical ethics which holds autonomous choice above all else.
References
2. Shickle D. The Mental Capacity Act 2005. Clin Med. 2006;6:169-173.
3. Rudnick A. Depression and competence to refuse psychiatric treatment. J Med Ethics. 2002;28:151-155.
ICM Case Summaries 