Sep 29
Morals and ethics - Case 3
You are called to “94year old female collapsed, possible OD”. On arrival you find an elderly, frail woman on the floor of her living room. By her head is an empty gin bottle and the packaging from a box of sedative anti-anxiety tablets.
The blister pack is empty, there is a suicide note on the table alongside.
Her family tell you she has recently been suffering deteriorating vision, increasing falls and the associated fractures often seen in such patients. Vehemently independent she has absolutely refused offers of domestic help or personal care from anyone other than members of her immediate family.
She has stated that she will not leave the home she bought with her husband as a young bride and in which she brought up her children. She is not breathing, profoundly hypoxic and faces imminent cardiac arrest.
This woman has apparently made her choice and decided to die.
It is your remit to rescuscitate her and you have no alternative choice of action … but is it truly in your patient’s best interests to do so?
Discuss.
September 29th, 2008 at 9:25 pm
Another excellent question.
Is it your remit? I’m not 100% where things stand for paramedics, but for doctors, yes, absolutely; it’s the law; I suspect the same is true of you guys. Is it in her best interest? Maybe not, but that’s a different q.
Aside from anything else, we don’t know the backstory is true… her family may be trying to off her for the inheritence.
Even if it truly is her choice, we still have an obligation to stop her; who knows, she may feel different in a few days.
Slainte
B
September 29th, 2008 at 9:26 pm
Surly and i have been talking about this recently; he feels that suicidal people should just staple DNR paperwork to their chests before attempting suicide, although i’ve pointed out that legally, the case could be made that being suicidal means you’re not of sound enough mind to declare yourself a DNR.
Similarly, we had a patient who needed to be intubated, but–per the family–in his living will he has stated that he doesn’t want intubation. His new wife is distraught, doesn’t want to see her husband die, instructs the family to not bring in the living will. We know he doesn’t want to be intubated, but we have no power to override his wife’s wishes as the family doesn’t want to anger the matriarch, especially in a life or death situation.
In our case, the husband ended up with a trach.
Does the family want you to resuscitate? Are you legally obligated to? If either is yes, then i think you are forced to resuscitate. That said, these cases always make me really, really, really sad.
September 29th, 2008 at 9:28 pm
On another note… should assissted suicide be permitted? I think it should, and if so, then perhaps circs would allow for this woman to end her life, her way, with dignity. But they don’t. So there.
September 29th, 2008 at 9:31 pm
DNR is invalid in cases of parasuicide; you have to treat, at least until mental state can be re-assessed, and common law gives us the ‘right’ so to do. I suggest thta if the family DIDN’T want Rx, they wouldn’t have called the Boys in Green.
If in doubt, treat. The sin of COmission is far less than the sin of Omission…
September 29th, 2008 at 9:34 pm
My own POV in this situation, for whatever it’s worth: It is profoundly unfair to put you, the ambulance, the Emergency docs, or anyone else in this situation.
If I ever decide to take my own life, I will make sure it happens in such a way that nobody can intervene, so they will not be forced into exactly this sort of ethical dilemma.
September 29th, 2008 at 9:51 pm
*Puts on medic hat* Legally, unless I’m presented with an appropriately signed DNR, I HAVE to take action. I don’t have a choice.
*Takes off medic hat and puts on hospice/pallative care hat*
She’s lived on her terms her entire life and has made the decision that it’s time for her to go….but again, if she doesn’t have a DNR order and isn’t a hospice patient, I’m duty bound to provide care. Would I want someone to try to revive me (and, in doing so, prolong what I perceive my ‘agony’) if I were in her shoes? No, but I’d also make damn sure that I wasn’t found.
It’s quite the sticky wicket you’ve presented us with, Kal.
September 29th, 2008 at 10:31 pm
No, resuscitation may not be in the patient’s best interests - she wants to die, she’s planned it, she’s clearly in control of what she’s doing, and it’s what she wants, and had she been left to it that would be fair enough. But you’re involved now and it’s your responsibility to resuscitate her whether you/she likes it or not, sadly. Until the law changes and afford humans the same rights as dogs and cats in these situations (namely, the right to die with dignity), you’re pretty much screwed. As is she.
September 29th, 2008 at 10:45 pm
Turn this one the other way round. What justification would you have for failing to intervene? None it would seem in this scenario.
Are you acting as her advocate by omitting to intervene when presented with a critically ill pt? No, you do not know her. All your views are either personal or circumstantial. To fail to act would be paternalistic and asserts you know best for her in a snap judgement.
Does your professional code of conduct and ethics support you? No, although if you were a medic you would not be required to ’strive officiously to keep alive’ in a case of futility but the HPC aint gonna save your green clad skin in this case especially if the relis have a rethink later on.
How much reliance can you put on the pts ’significant others’ views. You can listen, but in the absence of any formal DNAR this is again circumstantial. How well do they really know her and what are the relationships like. This is also always subject to the cynical old caveat that ‘where there is a will there is a relative’. It is unlikely but this could be a set up or not how it seems in the heat of the moment.
Is a suicide note an advance directive? Depends on the content of it but obviously there was nothing in it which said ‘goodbye cruel world, and PS dont resuscitate me’. As you cannot assess her competence prior to the apparent act then what proof is the note.
The pragmatic view on this one is that you need to intervene but nature and the pts actions will call the decider in the long term. To do anything else is to overstep the mark, and societally we remain ill-prepared to make this crossing of the Rubicon particularly in the pre-hospital emergency setting due to the uncertainties of situations.
This case is sad and very unfortunate but we are individually responsible for only our own lives. As Healthcare Professionals we can never presume, only offer the skills at our disposal unless the pt has taken the responsibility to properly direct us otherwise. Just because she was elderly does not remove her rights or cause us to apply a lower standard. She had the right to act as she did but as an adult she also had the responsibility for making her ultimate wishes clear.
Lucy
September 29th, 2008 at 11:06 pm
Assisted Suicide is legal in my state. I support it.
If the woman wants to die in her home at the end of her life.
Let her.
RD
September 29th, 2008 at 11:19 pm
Since you’ve been called, you have to tend to her.
My real question is with the family. If they know she wants to die, why would they call you?
Our hospice people tell us repeatedly NOT to call medical if the loved on is dying or appears dead, because if the ambulance comes they will try to revive the dying person. (Yes, I know she isn’t using hospice…)
I hope when I am ready to die I am able to do just that, without unwanted measures or interference.
September 29th, 2008 at 11:48 pm
Suicide is selfish. Think of the people you leave behind! All this talk of choice is rubbish. The simple fact that one is alive and on this wonderful planet means you are obliged to live as long as God (and the Scottish Ambulance Service) decree, and make it a good one while one is here.
September 30th, 2008 at 12:33 am
This decision is easy. You have no choice. She should have told relatives she was leaving to visit somewhere, then pop the pills. One of my clients did that and was successful. Another tried but was found. She is in a nursing home now with a feeding tube. So much sadder.
September 30th, 2008 at 12:34 am
It’s very likely the family members called for assistance because they did not want to feel they did not do all they could to save her. It was her choice to attempt to end her life but when they found her before the deed was done it brought them into the decision making process whether they wanted it or not. They might have wanted to let her go knowing it was what she wanted and may have been okay with it had she been successful. But they simply didn’t want to be part of it. So they called. Obviously there is no way I could know that - but it seems logical to me.
Regardless, once you are called - you have to treat.
September 30th, 2008 at 12:54 am
Lucy commented (in favour of intervening):
“To fail to act would be paternalistic and asserts you know best for her in a snap judgement. ”
It seems to me that the same argument can be used *against* intervening. Choosing to resuscitate could be viewed as “paternalistic and assert[ing] you know best for her in a snap judgement.”
Damned if you do, damned if you don’t. A very sad and difficult ethical conundrum.
September 30th, 2008 at 1:00 am
FireDad says, “Unless family members hand me DNR papers, we do it. I know, I know. Their problems are not my problems and it is going to BE my problem if I don’t do something.”
I default to his answer even though my heart breaks for this old lady.
September 30th, 2008 at 3:11 am
I once spoke to a psychologist who’s interested in people who’ve nearly died in suicide attempts but have been resuscitated. The psychologist told me that a very common theme in their last thoughts before unconsciousness was the idea that they were in those few moments suffering all the misery they would have suffered for the rest of their natural lives, coupled with the awareness that had they chosen to live they would have had the opportunity to change things to make themselves happier. An elderly woman in that situation could after resuscitation decide to accept home care from someone outside her family and to take other steps to become happier. Or she could make another suicide attempt and plan it in such a way that she’s not found in time.
The question of whether she’s been hypoxic too long for any sort of meaningful life is a separate one, and I don’t think it should be considered differently in a situation of attempted suicide than it would be in a case where the hypoxia stemmed from another cause.
September 30th, 2008 at 3:16 am
I think that legally you would have to attempt to resuscitate the patient. However, I would take the long way to the hospital and not try too hard. Of course, I also think that suicide should be legal.
September 30th, 2008 at 4:45 am
That is so difficult. I know of a case of a proud old lady who’d suffered several debilitating strokes after a lifetime of sport and social activities. Her post stroke courage and determination in terms of physiotherapy and exercise impressed everyone who knew her. Finally against her will, a good nursing home had to be arranged.
Soon after that she had another series of strokes, losing voice and all remaining control of bodily function. Her closest relatives were asked if she should be revived and everyone, Doctor included, felt a person of her character and abilities should be allowed to let her body go. She’d liked the Home, had made friends, but once there was only a mere shell of herself remaining, then why? I should add that this was many decades ago.
I think it was more common in those days for relatives to maintain closer contact. If the old lady you mention who wanted to leave her body behind had loneliness as a factor in the decision, then that might be possible to consider in terms of solutions, but hell, I don’t know, I really don’t.
September 30th, 2008 at 6:57 am
Probably not in her best interest but you
have no option but to try resuscitation.
People must do these things properly like a
living will etc.
September 30th, 2008 at 7:43 am
Obviously, you had no choice but do your “best” but I don’t envy your choices…like the man said damned if you do, damned if you don’t. As a survivor of a suicide attempt I’m glad (now) that the ambulance arrived when it did and the services did what they had to bring me back. However, today when I am thinking of a friend who committed suicide one year ago today I can only hope she is at peace at that those of us left behind will find the strength to move on without her. The only thing that has got me through this last year has been that I truly believe she wanted to end her life. But the suffering she left behind she would never had wanted.
September 30th, 2008 at 8:46 am
Not in the best interests of the patient, the country or your peace of mind . But there you go, if the family are there and want her saved for whatever reason then at least someone will benefit from your efforts (hopefully)
September 30th, 2008 at 11:59 am
Damn. Yer just a minx Kal, what with all these ethical questions!!
As has been said, you’ve got to. However fair or unfair on patient or relatives. We are bound by law to go the full resus if there is evidence of ’status compatible with life’. Or at least give it a go.
In those wee dark corners of the mind that i try not to look into very often, the thought has occurred to me……
1) Family out the room (Resus is not a pleasant procedure to see performed on a loved one)
2) Total understanding and trust with your crewmate
3) Make all the correct motions of attempted resuscitation
4) We have the authority to Recognise Life Extinct after 20mins of resus attempt with Asystole still showing.
Course if she’s not Asystole, thats a different matter. Like i said, the subject has been discussed before (in station during the ‘lively’ debates) but i dont think anyone of us would stand aside and let it happen. No matter what the situation. Just wanted to stir it a bit.
September 30th, 2008 at 12:15 pm
You’re an ambulance tech/paramedic. Your job is to save lives. It sucks that she didn’t succeed, since her intent is so obvious, but I too agree you HAVE to try. With her current condition, and her advanced age, she might well not survive the attempt to resuscitate (sp?Phlllhhbbhhttt) anyhow. Chest compressions will probably break her brittle ribs. Her mind may already be shut down from lack of air.
You, however, are young, you WANT to live, and you deserve to live to the best of your ability, which includes NOT losing your job due to improper conduct. Yeah, it breaks my heart too, because my first thought was “let the poor dear go” - but selfish as it may seem, you have to think of YOU too. You’re part of this “contract” of care.
September 30th, 2008 at 12:16 pm
Much as you may want to let her go with dignity, from what’s been said above you have no choice but to try. Awful situation for all concerned, though. As a point of interest, do ‘Living Wills’ have any standing in Scotland?
I once heard of a man, a retired doctor, who killed himself after being diagnosed with advanced Prostate cancer. He was in his 70’s and aware of the likely outcome. He gassed himself in his car, in his own garage, after posting a letter to the local police station telling them where to find him. By the time they received the letter and attended, he was long gone. In all honesty, I can think of worse ways to go, and he avoided any possibilty of being found too soon. Not nice for the poor coppers, but they at least knew what they were going to.
September 30th, 2008 at 12:54 pm
You have no choice.
I personally would not have called you in in the first place but you are there so you get on with it.
September 30th, 2008 at 1:18 pm
A tricky one, definitely. Unfortunately, I have to echo the other comments here: there’s what you SHOULD do, and what you HAVE to do. We all know that resuscitating a 94 yr old frail woman who’s decided to end her own life and is already respiratory arrested does not lead to a good outcome either physically (or mentally, should the physical body survive), but that doesn’t change the fact that we have no choice but to.
If her suicide note had been in the form of a living will lying on the table, would the choice have been different? YES. And damn well should be. Living Wills are legally binding in Scotland, and must be adhered to. In this case, you could have used it to armour-clad your ass over not resuscitating her. Yeah, there would have been a case to hear afterwards, but you’d be covered.
However, I see it as a sad reflection on our society that such a case needs to be made. She’s independent, 94, has had a good life and has steadily seen her own deterioration change her from the woman she was into a frail shadow of herself. She’s made her choice, and it should be respected. I know people might argue the ’sound mind’ idea, but frankly, I think that in realising that there’s a huge gulf between LIVING and simply LIFE, she’s shown extremely sound mind.
Damn, but I hope someday this country comes around to that fact. Keeping people alive, forcing life on someone who no longer wants or enjoys it or has the capacity to enjoy it is not only unethical, it’s plain unfair. Having seen the end result of OOHCA patients in just such circumstances, without adding in the extra wrinkles of drugs and alcohol and the psychology of attempted suicide, I would go so far as to say that resuscitating her is so far from being in her best interests that it verges into deliberate cruelty.
None of which changes your position.
It’s hard, and it’s not fair, but until the legal requirements change, then there’s not a single way to resolve this, Kal.
I can only hope that when my time comes, whether by my own hand or not, the law will get around to actually protecting my best interests, and not its own…
September 30th, 2008 at 1:51 pm
Unfortunately her wishes dont come into the this one, without a signed and witnessed DNAR you have duty to resusciate.
What happens when the family find out you didn’t and blame you for the death of there family member……….? Sometimes even though you feel you want to go with what they want you have to do the job your there to do.
September 30th, 2008 at 4:07 pm
Everyone seems to have answered this, I can only agree. No it is not in the patients best interests, she has made a decision, but you have no choice, you must resuscitate. Rightly or wrongly.
September 30th, 2008 at 4:38 pm
@11 James:
Maybe the ones left behind will be glad when I’m gone. Maybe that’s the best thing for the world.
And “God” doesn’t enter into it. There is no God, and life is pointless. You’re here or you’re not. And it doesn’t matter one single whit to the entire universe either way.
September 30th, 2008 at 6:49 pm
Clutch your chest, fake an MI, collapse to the ground.
Let the next team on scene work out which to deal with first:
- Apparently health medic who appears to have undergone a cardiac issue
- 94 year old female with depressed breathing
September 30th, 2008 at 6:50 pm
I know from your previous posts you can read a room very quickly, but in this (theoretical?) case, you really can’t clearly say whether this is an assisted suicide, suicide or attempted murder. So you have to try to resuscitate. How hard you try is up to you and your colleagues.
October 2nd, 2008 at 1:14 am
Resuscitate and be damned. If she wants to sue, then at least she is alive to have that choice.
October 2nd, 2008 at 3:25 pm
Been away for a few days, otherwise I would have said this sooner.
This is the third time in a week that I’ve been reminded of a play by Brian Clark, “Whose life is it anyway?” It is about a sculptor who has become quadriplegic as the result of a car accident, and is under care in a hospital, so is unable to commit suicide. His argument runs that having looked at everything with a sound mind, he no longer wishes to live. Because the doctors cannot assist his suicide (which would be necessary in this case), his lawyer makes a plea on his behalf. It raises as many issues as it answers, and presents arguments both for and against euthanasia.
On the other hand, one of my closest friends killed herself a little over ten years ago. She took 172 paracetamol, 20 tamazepam and washed them down with half a litre of vodka. I found her whilst she was still conscious, so she should have been save-able. But she’d planned for that and taken half of the paracetamol six hours earlier. If the lady you present really wanted to take her own life, she would have managed it.
If you didn’t treat, and it turned out that this was a thinly disguised murder, where would you stand? But if you treat and she doesn’t want to survive, she’ll either have planned for it already or will plan better next time. As has been mentioned - in this profession, we don’t have a choice.
And for those left behind by a suicide, you will do immeasurable good if you do attempt resuscitation. I have now dealt with how I feel about my friend’s death, to the point that when I think about it I no longer feel pain. But the words that were spoken to me by the ambulance crew are still with me now - “We may not be able to save your friend, but we will try everything we can.”
Ghostie
October 3rd, 2008 at 10:47 am
Yes, you have to resuscitate her. If what the family say about her wishes is true then they shouldn’t have phoned you. I often think that these decisions are more important to discuss within families than with medical staff. It’s then up to the family to be the patient’s advocate and not chicken out (as this family have done) when the time comes. I’ve already made my parents start thinking about DNAR forms, extent of treatment and where they want to die and they’re only in their late 60s!
In terms of assisted suicide or euthenasia. Maybe people have the “right to die” but you don’t have the right to ask me to kill you.
Here’s an ethical dilemma I had a couple of nights ago. Old lady with terminal cancer who has known for 6 months. Her daughter died of cancer a few years ago and at the time her husband said “I never want to go through that again,” so she has not told any of her family about her own diagnosis. It’s 2am (it always is!) and little old lady is going to die very soon. She is comfortable, not confused and adement that we DO NOT telephone her family to come in and be with her. What do you do?
October 4th, 2008 at 7:37 am
Ghostie…hope the day I don’t feel pain about my friends suicide comes soon…this is the pits x
October 4th, 2008 at 9:14 pm
Heyhoo - It didn’t happen all at once, but one day I found myself thinking about her and it didn’t hurt quite as much. I can’t say that I know what you’re feeling - it’s different for everyone - but I have been there too, and there is light at the end of this tunnel. My thoughts and prayers are with you. Ghostie x