Care and competence in resuscitation decisions
Online posting: May 3, 1996
Published in print: July 15, 1996 (CMAJ 1996;155:164-165)
Re: Letter to an ethicist: resuscitative interventions, by Dr. John
J. Quinlan and William A. Cook, CMAJ, 1996;
154: 887–888 [full text / résumé]
The letter by Dr. John J. Quinlan to Dr. William A. Cook, despite
its omission of important clinical details, raises serious
questions and concerns. Quinlan's first case was an elderly man
who had a postoperative cardiac arrest and was subsequently
unconscious in the intensive care unit (ICU) for 3 weeks. We are
then told that he was transferred to the "palliative care ward,
where a ventilator, respirator and total parenteral nutrition and
hydration were maintained for another 3 weeks." Quinlan asks
whether the "plug should have been pulled" after the first 3
weeks, since the patient was "obviously a vegetable." We are then
told, without further explanation, that the patient is now
perfectly well and 85 years old.
Cook's response misses several key points. First, it is difficult
to imagine anyone calling a unit with mechanical ventilation a
"palliative care ward." By definition, "palliative care implies
the withdrawal of active curative treatment of the patient's
condition following recognition that the patient has a fatal or
terminal disease which cannot be cured."[1]
Second, the patient was, in retrospect, not a "vegetable" if he
could subsequently make a full recovery. Good ethics follow from
good medicine. An appropriate and sequential neurological
evaluation of the patient would have provided some clues about
the eventual outcome for this patient.
In the second case, in which a man 42 years of age stated that he
did not want to be resuscitated, the question is strictly one of
the patient’s competence. A competent patient has the right to
refuse any treatment. If indeed the patient is found to be
incompetent because of clinical depression, then he should be
assessed and treated for his psychiatric condition, and his
family should be involved in his care. "The mere fact that the
patient/family/proxy selects a management option with which the
physician disagrees does not make them incompetent."[2]
Stephen Liben, MD, CM, FRCPC
Director
Pediatric Palliative Care Service
Montreal Children's Hospital
McGill University
Montreal, Quebec
jlamnur@mchnurse.m
chis.mcgill.ca
References
- Doyle D, Hanks GWC, MacDonald N: Oxford Textbook of
Palliative Medicine, Oxford University Press, Oxford,
England, 1993: 497
- Koch KA: The language of death: euthanatos et mors. Crit
Care Clin 1996; vol #: 1
[Dr. Quinlan responds:]
My original letter was written not as a clinical description of
the management of either of the patients but as an example of the
ethical dilemmas that confront us, often suddenly and at an
inconvenient time (0230 hours) when we have no consultative
assistance.
Granted, I omitted the clinical details of the unexpected
survival of my patient in the first case. Believe me, the
clinical procedures were intensive and involved many visits by a
team of at least five physicians and surgeons.
Dr. Liben criticizes our transferring the patient to palliative
care. The transfer was, to a large extent, an administrative
decision based on the limited number of ICU beds and the
hospital's accounting manoeuvres. The care the patient received
was not the equivalent of that available in a full ICU but was
still acceptable to the team of physicians, after some discussion
with the family. In his second paragraph, Liben defines
palliative care. The definition matches almost exactly what was
done — care was provided for a terminal illness that could not be
cured. The diagnosis of "terminal" was obviously mistaken. A
"retrospectoscope" usually gives a much clearer view of the
options.
The second case more or less took care of itself. The
"retrospectoscope" has not helped solve this problem. The US
Congress has just passed a law that would solve the legal problem
by declaring that assisted suicide under certain, unspecified
circumstances would not be a crime — a definite step onto a
slippery slope. The ethics of the situation still pose a problem.
John J. Quinlan, MD
Brantford Clinic
Brantford, Ont.
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