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Fri Apr 25 05:20:50 BST 2008

Dear Ken and all,

If a patient is not "of sound mind" then they should / can be detained under
the various Mental Health legislation (admittedly this will vary from
country to country or state to state).  Once detained a duty of care concept
applies and the patient's wishes are not over-riding.

An key issue arises when someone clearly wants to be allowed to die.  We
generally define a desire for death as an "unsound" desire and therefore
suicidal ideation is defined as "insane" and warrants detention under Mental
Health Legislation.  One could argue the validity of this and people do, but
it pretty much accepted unless one is in "the terminal stages of a terminal
illness".

So in Ken's hypothetical case one issue is whether you feel the patient
really understands the consequences of their decision.

I can imagine a variant of this scenario where the patient's wishes may be
adhered to. 

Imagine the patient is 95 years old, has known end-stage respiratory
failure, is on home oxygen and has a painful disseminated incurable end
stage cancer.  
The patient had already signed a Do Not Resuscitate order prior to being
shot.  He even has it tattooed on his chest (I have seen this).
He is a retired eminent trauma surgeon who has kept up to date with the
advances in the literature and is very well informed.   
He is lucid and say he really wants just to be made comfortable especially
as given his pre-morbid conditions the chances of him surviving surgery
would be very low anyway.  
His family all agree they would prefer him to pass peacefully with them
present. 

In that case I would have no problem with giving him adequate analgesia and
focusing on comfort care.  Would anyone here force other treatment on him?
If so - with what justification?

However consider the same situation in a young emotionally distressed
previously well patient who is agitated and refusing everything?  I would
probably detain that person under the Mental Health Legislation here and
provide the care necessary to try to keep him alive.  That may include
sedating / intubating and ventilating him.

In the middle somewhere there will be a gray zone, which may depend a bit on
our own individual prejudices.  I find it helps me to try to imagine that I
am the patient, not the doctor and to think would I want some other doctor
to over-ride my decision for my own good?  In gray zone cases ideally I try
to get at least one other senior doctor to confirm my view before
documenting the path I will follow.  This acts a reality check for me.

I want to avoid the trap of patronising arrogance because "I am a  doctor
and I know best".

We need to think about what we do and not just mindlessly follow recipes.
Patients should be allowed to control their own destiny and to make
decisions, even on occasion they should be allowed to make bad decisions....
and guess what? Sometimes doctors make bad decisions too...

As you say Ken - Autonomy and equipoise.

My 2c worth.

Regards

Bill

A/Prof William Griggs AM
Director Trauma Services
Royal Adelaide Hospital
South Australia
wgriggs at bigpond.net.au

BTW Did you know that we all suffer from a sexually transmitted degenerative
disease with 100% mortality?  it is called Life.

-----Original Message-----
From: kmattox at aol.com [mailto:kmattox at aol.com] 
Sent: Wednesday, 23 April 2008 21:36
To: Trauma &amp; Critical Care mailing list
Subject: Re: Lawsuits, etc

Change the focus and ask the questions.  A fully consious patient has a
tender abdomen following a GSW and also needs a blood transfusion.   The
patient refuses both, yet the doctor insists the patient should not die on
his shift.  Does the doctor have the right to sedate the patent so as to
remove the objections, with the sole purpose of doing a laparotomy and
giving blood.   Autotomy and equipose.  

K

<snip>

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