What is the most appropriate response in this situation? A patient who is in a great deal of pain, weak, and c

Question

Joe H, a 59 year-old male, has been diagnosed as having cancer. His condition is rapidly deteriorating. Joe H has requested that he not be resuscitated if he should go into cardiac arrest. He has also stated that he wishes no further treatment. Dr.W, who is Joe H's personal physician, and Dr.R, the oncologist in the case, agree that he should not be resuscitated, and “Do not resuscitate" is written on his chart. However, when Joe H begins to experience severe internal bleeding, he asks his physicians if they can do something. Whether Joe H is competent at this point is unclear. Dr. W does not want to take measure to stop the bleeding, in keeping with Joe H's original request for no further treatment. Dr. R sees the request "to do something" as taking precedence over the earlier request for no further treatment. If they do not act quickly to stop the internal bleeding, Joe H will die as a result of blood loss.

Answer 1

You always have to take a verbal request as taking precedent over a written earlier request. I am pretty sure that most doctors are well versed in the legal aspects of this.

My father had a DNR and a request for no further treatment. (He had heart issues with an internal defibrillator installed). When he got to the ER the on call cardiologist (not my Dad's cardiologist) explained to him that he was in an abnormal rhythm and there was some thought that placing in a pacemaker might be helpful.

Needless to say, my Dad had this needless surgery and died a few hours later. I was annoyed at first and then in the long run I realized that Doctors are just like all human beings, they go on their best judgment. Medicine is a science, but it is also an art. Many times there are to 'correct' answers.

Answer 2

This is more of a legal question than an ethical one. Joe will not live long because of the cancer. Regardless of what is done to treat him, his death is imminent. What is causing the "severe internal bleeding"? External bleeding may be controlled by direct pressure, but internal bleeding requires invasive treatment and may hasten death.

Joe has requested that he wishes no further treatment. Was this request made in writing? Most patients are counseled to have an advance directive or living will. In the advance directive the patient may also designate a person to make decisions in the event that he becomes incapacitated. This may be a separate document, the medical durable power of attorney

Answer 3

Legally, it depends on which doctor checked in the patient R or W. Normally, in such circumstances that is the person who gets to make the call. By the way, a DNR needs to removed in writing whenever possible. If a doctor is willing to put it in writing then the other doctors must recognize the change as binding. I swear i've seen this question before just not so detailed. Here is how it works. The general prectitioner may be the doctor who gets you into the hospital. That makes you his patient and makes the decision his call. The oncologist may get called in as a consult and have no say so in the matter at all. If the oncologist assumes responsibility for the patient then it is his call. If the hospital on call doctor makes the call then it is because the other doctors are not there to question it. There is a hierarchy in hospitals that starts with doctors on staff, doctors of record, doctors on consult, doctors on call, residents, interns and then nurses. Everybody is ther to save their license so they don't mess with the hierarchy or the law. So once again, get a medical power of attorney and the question is moot. The person designated is the person who will make the call if the patient is no longer able to rationally make the decision.

Answer 4

DNR usually does apply for the use of life suspending mechanical ventilation and cardiac care. Since Joe H. has a standing DNR the act to stop the internal bleeding really doesn't correlate with the DNR. You would prevent the internal breathing. If Joe H. requests help you need to honor the verbal request.

Answer 5

Well if the bleeding was caused by cancer then it would be best to not do anything about it since he requested no furthur treatment, especially with the DNR order. Like it or not, the doctor has to follow the patient's wishes.

Answer 6

This is tricky even though he has cancer that a DNR can mean several things to different people if he is very near death like a week or less make him comfortable. if not give him the transfusion so at least he has the strength to rally. its probably inhumane to keep him from getting a transfusion but if its a stomach bleed they can give him medicine to prevent it in the same token if Joe fell and broke his leg wouldnt the dr try to immobilize it give him pain meds etc the dr wouldnt ignore it certainly

Answer 7

Shoot Joe and put him out of his misery. Seriously though, if you question his competence then send him to a psychiatrist. Quickly though. Why wouldn't you stop the bleeding and make the guy as comfortable as possible until his death. He asked not to be resusitated, I'm assuming in the event that he dies. He's not dead yet, is he? He's not in cardiac arrest? Then patch the poor bugger up, and give him some morphine!

Answer 8

Lucid or not you help him out.

This sounds like a Monty Python skit.

DNR patient-- "listen I'm competely coherent, I want treatment."
Doctor with 3 assistants-- "Note how the patient loses all mental capacity nearing their death"
DNR patient-- "Huh?! I just told you I'm mentally well-- but I have an absess of something painfully uncomfortable growing in my abdomen"
Doctor--"See how the eyes wander"
DNR-- "Look here, I need some attention-- aww hell, I'm calling my family....."
Doctor -- "Like a zombie animated by the subconscious, truly amazing specimen today, you should be thankful to see this abnormality"
DNR-- "...yeah this freakish hospital already pronounced me dead, how'd I get in here-- I feel like all I have is a bit of gas"
Doctor--"Don't worry, you get used to seeing this all the time in this ward. Time to move on. Intern please turn off the life support. Good, turn off the lights as well, A nurse will clean the room out later"
DNR-- "What the--- HAAAAY you locked me in here!!! What the hell is going on?!" *gas pours in through the ceiling*

Answer 9

It seems to me that they could be sued either way. Either they uphold his previous decision and the greving family sues for wrongful death after the paitent's request for care, or they give him the treatment that he's now asking for and after recovering he states that he was not of sound mind and they violated his first request and he sues for emotional damages of being forced to live longer with the pain.

But, aside from being sued, if he's requesting assistance they should give it to him, i was under the impression that DNR referred to after he'd gone unconsious, if not already died. And the order kicks in when making the decision wether or not to try to resuscitate him. I mean...isn't that what resuscitation is? Bringing them back from completely dead or so close to being dead they the paitent could not tell them to stop, ie being incompassitated?

Answer 10

in case you're able to authority , if I understood properly then you definitely could locate out who's doing it and confront that individual gently via with austerity. opportunities are high that if a individual is in many circumstances doing some thing beside the point they do no longer see the place the harm is and don't understand even once you have defined them, via fact of this they do it in the 1st place. the perfect worldwide we see in the action pictures that all people can communicate reason to somebody else, regrettably rarely exists. subsequently you may watch your back, and be careful so this does not backfire. Manners that are logical to us ought to propose skinny air to somebody else. save your endurance and act subsequently. solid success.