Psychosomatics 48:10-15, January-February 2007
doi: 10.1176/appi.psy.48.1.10
© 2007 Academy of Psychosomatic Medicine
DNR Versus DNT: Clinical Implications of a Conceptual Ambiguity: A Case Analysis
Robert D. Martin, M.D., FAPM,
Mary Ann Cohen, M.D., FAPM,
Laura Weiss Roberts, M.D., FAPM, M.A.,
Sharon M. Batista, M.D.,
Dan Hicks, M.D., FAPM, and
James Bourgeois, O.D., M.D., FAPM
Received June 23, 2006; accepted July 6, 2006. From the Dept. of Psychiatry, Long Island Jewish Medical Center, Albert Einstein College of Medicine (RDM); the Dept. of Psychiatry, Mount Sinai School of Medicine; the Dept. of Psychiatry and Behavioral Medicine, Medical College of Wisconsin (LWR); the Dept. of Psychiatry, Mount Sinai School of Medicine (SMB); the Dept. of Psychiatry, Georgetown University Medical School (DH); and the Dept. of Psychiatry, University of California, Davis Medical Center (JAB). Send correspondence and reprint requests to Mary Ann Cohen, M.D., FAPM, Clinical Professor of Psychiatry, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1009, New York, New York 10029. e-mail: macohen{at}nyc.rr.com
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ABSTRACT
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Psychiatrists who practice psychosomatic medicine are routinely called upon to help resolve ethical dilemmas that arise in the care of patients near the end of their lives. Psychosomatic-medicine psychiatrists may be of unique value in these situations because of the clinical insights that we bring to the care of the dying patient. In particular, our subspecialty brings expertise related to the evaluation of decisional capacity of patients who are faced with accepting or declining end-of-life clinical interventions, such as resuscitation and intubation. In this first entry in a new bioethics case series in Psychosomatics, we will lay the groundwork for examining a complex patient case and provide an illustrative analysis of the end-of-life care issues that may be addressed by psychiatrists who practice psychosomatic medicine.
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INTRODUCTION
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Psychiatrists who practice psychosomatic medicine are routinely called upon to help resolve ethical dilemmas that arise in the care of patients near the end of their lives. These ethical "knots" are often very difficult to unravel, because they represent the complex tangling of clinical, legal, societal, and personal elements. Psychosomatic-medicine psychiatrists may be of unique value in these situations because of the clinical insights that we bring to the care of the dying patient. In particular, our subspecialty brings expertise related to the evaluation of decisional capacity of patients who are faced with accepting or declining end-of-life clinical interventions such as resuscitation and intubation. We also help in managing the implications of the dying patient’s evolving decisional status, for example, with families and multidisciplinary clinical care teams. In this first entry in a new bioethics case series in Psychosomatics, we will lay the groundwork for examining a complex patient case and provide an illustrative analysis of the end-of-life care issues that psychiatrists who practice psychosomatic medicine may address.
Two radical changes over the last half century have had a major impact on the practice of medicine in the United States and in many other countries throughout the world. One change was the development of major technologic and scientific advances in medicine, enabling people to live longer, healthier lives and to live longer with chronic illnesses that were previously considered fatal. Also, other technological advances have led to the development of cardiopulmonary resuscitation (CPR), as well as sophisticated life-support technologies, hemodialysis, and organ transplantation. Although these life-sustaining and life-saving procedures have had a profound and positive impact, they have considerably complicated healthcare decision-making. Bioethical dilemmas that resulted from these procedures were exemplified in landmark legal cases including the case of Karen Ann Quinlan1 in 1976 and the case of Nancy Cruzan2 in 1990.
The second (and radical) change was the civil rights movement. The civil rights movement led to the patient rights movement and to a change in the physician–patient relationship, from somewhat paternalistic to more participatory3 and autonomous. In 1991, autonomy was codified in the United States in the Patient Self-Determination Act.4 The Patient Self-Determination Act requires healthcare facilities to inform all patients with decisional capacity that they have the right to accept or to refuse medical care. Patients also have the right to provide healthcare facilities with Advance Directives so that their wishes regarding medical care will be honored, even if they should lose the capacity to make medical decisions.
The collision of technological advances in medicine and changed attitudes toward the rights of individuals in governing their personal health care has led to numerous ethical questions at the end of life. As a result, healthcare facilities have had to develop mechanisms to address bioethical dilemmas. These mechanisms can include, but are not limited to, bioethics committees, optimum-care committees, ethics consultation services, and dispute mediation. Since resuscitation has become available, its use or misuse has led to the development of Do-Not-Resuscitate (DNR) or No Emergency Cardiopulmonary Resuscitation (No Emergency CPR) policies in healthcare facilities. Despite these advances and changes, bioethical dilemmas continue to arise in health care and can contribute to the anguish of patients, families, and their caregivers.
Psychosomatic-medicine psychiatrists are in a unique position to help address these bioethical dilemmas, to teach bioethical principles, and to deconstruct the challenging questions that may obscure sound clinical decision-making in end-of-life care. The assistance that psychosomatic-medicine psychiatrists can offer to help resolve ethical dilemmas pertaining to these two domains is suggested by the case that follows. In the particular case we have chosen to present, there was no psychosomatic-medicine psychiatry department or availability of the services of a psychosomatic-medicine specialist. Also, since none of the authors of this manuscript participated in the treatment of the patient presented, many of the details about medical care were scant or unavailable. Nevertheless, members of the Bioethics Subcommittee of the Academy of Psychosomatic Medicine have selected this case to because it exemplifies a complex series of ethical issues that frequently present in end-of-life care.
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Case Report
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"Ms. A" is a 91-year-old woman who was found lying on the floor of her house by her visiting nurse. The nurse called 911, and an emergency medical team arrived. When Ms. A was examined, she was found to be alert and responsive. Although she initially objected to going to the hospital, she was easily convinced by her nurse and the emergency medical technicians that a more extensive medical evaluation was indicated. Her daughter and son-in-law were notified and met her at the hospital.
In the Emergency Room, Ms. A was found to have hypothermia, with a temperature of 94°F, and hypotension, with a blood pressure of 56/28. She was alert and verbal, but oriented as to person only. She believed the year was 1941 and that she was in a hospital different from the actual one.
Her history of present illness revealed that Ms. A had been living alone with only minimal home help and a visiting nurse until about 6 weeks before her admission. Until that time, her health and cognitive status were relatively intact. She had a history of hypertension and diabetes mellitus. Her diabetes was controlled by diet alone. She had been able to manage her affairs, pay her bills, and attend to activities of daily living as well as instrumental activities of daily living and was described as generally amiable and cooperative. In the 6 weeks before her admission, Ms. A had developed new medical problems but was unwilling to have them extensively evaluated. She developed new-onset dyspnea on exertion and pedal edema, and was thought to be in congestive heart failure by her primary physician, who saw her at least one time during this period. She was started on furosemide by her primary physician with some improvement in the pedal edema. However, she was becoming increasingly oppositional and was described as "confused" and "cantankerous." She was reported by her visiting nurse and by her daughter, as eating less food than she had been eating previously. She refused an increase in home care from 4 hours to 24 hours per day, although she seemed less able to manage for herself. She had not paid some of her bills and had mailed others out with incorrect addresses. Her home health care was not increased because she refused to allow new caregivers to come in, although she continued to accept the care that she was getting from a home attendant and the visiting nurse. It was her regular visiting nurse who found her on the floor on the day of her admission.
Ms. A’s treating physician, an internist, believed that Ms. A had the capacity to make decisions about her medical care when she was admitted to the emergency room. History from her daughter and son-in-law revealed that Ms. A had signed a DNR form, a healthcare proxy, and a Living Will in a lawyer’s office 2 years earlier, when she executed a will for the first time. Ms. A’s daughter and son-in-law believed that Ms. A was unable to make decisions for herself because she appeared to be confused and had also seemed confused at times for some weeks before her emergency room admission. Ms. A’s daughter had been designated as the healthcare proxy for medical decision-making, but her daughter was not willing to assume the decision-making role unless Ms. A were to be determined to be lacking in decisional capacity by a psychiatrist.
Her treating physician disagreed with Ms. A’s daughter and son-in-law and believed that the patient’s medical decision-making capacity was intact. Because of this disagreement, her son-in-law asked the internist for a psychiatric consultation to determine Ms. A’s decision-making capacity. Her daughter and son-in-law left her bedside for a few hours. When they left she was stable, alert, and appeared comfortable. During that time, the consulting psychiatrist evaluated Ms. A and confirmed the internist’s opinion that Ms. A had the capacity to make medical decisions for herself.
Her daughter returned later that day and was told that Ms. A had been moved to an intensive care unit (ICU) and that there was considerable medical debate regarding what to do for her. Ms. A’s treating physicians believed that treatment of her condition was medically futile and that she should be provided with comfort-care only. Her blood pressure was low, her renal output was failing, and the treating physician perceived Ms. A as "slipping into death." Her physicians did not think she should be vigorously treated, and they made it clear that they were not going to use vasopressor medications to raise her blood pressure, largely because the patient had stated she did not want them when she was admitted to the Emergency Room. Her daughter and son-in-law wanted them used. The controversy rested on the treating physician’s interpretation of Ms. A’s condition as medically futile. Her treating physicians also based their decisions on her previously written DNR consent and her recently expressed refusal of vasopressors. Her physicians did not seem to be sensitive to the concerns of her daughter and son-in-law.
Her daughter wished "all reasonable measures" to be applied to save Ms. A, that is, "any measures to sustain her life," including the use of vasopressors. Her daughter and son-in-law viewed Ms. A as being acutely ill, with a recent deterioration of her medical condition over a 24-hour period superimposed on the chronic deterioration over a period of the 6 weeks before her admission. The reason for her acute deterioration was never clarified.
Ms. A’s daughter wished her mother to be treated aggressively. Her daughter was also informed that the psychiatrist had determined that there was full medical decision-making capacity shortly after her admission and had determined that Ms. A’s wishes should be followed.
The physicians treating Ms. A felt that her expressed wishes regarding her medical treatment should be honored. They based their opinion both on her responses to their questions to her on admission and evidence from her signed DNR consent form (executed 2 years previously). Ms. A had specifically refused to accept treatment with vasopressors when she was initially evaluated while she was alert. Ms. A’s daughter and son-in-law believed that not giving vasopressors was equivalent to withholding reasonable care in an acute medical situation.
The medical team insisted that her earlier DNR signature and her expressed wishes, along with the psychiatrist’s capacity determination, were adequate evidence that she did not want vasopressors. The psychiatrist had asked Ms. A if she wanted vasopressors and she said "No." The medical staff accepted the decision of Ms. A and the psychiatrist’s determination as further evidence that permitted them to withhold drugs that might improve her blood pressure. It was not fully clear whether vasopressors would have helped, in light of acute renal failure (evidenced by no renal output), but the issue was decided anyway by the staff’s reference to the previous DNR order. When her son-in-law suggested that this was "DNT (Do Not Treat)," not merely "DNR," her physicians bristled and objected to such a designation. The vasopressors had been withheld since her entry to the emergency room. Ms. A’s condition appeared to be deteriorating, and she seemed to be in delirium and no longer able to communicate her wishes. Her delirium was not reversed.
The following day, Ms. A was unresponsive and in a coma. The treating physicians recognized the need for surrogate decision-making by Ms. A’s daughter, whose designation as healthcare agent was now in effect since Ms. A did not have capacity to make decisions for herself. The medical resident met with Ms. A’s daughter, asking whether she wanted vasopressors used, and explaining that her mother’s condition had deteriorated to the point where she was dying and would die soon if vasopressors were not administered, although there was little to no hope for recovery even with vasopressors. Ms. A’s daughter did not know what vasopressors were and asked a number of questions about her mother’s condition and about vasopressors. Once her questions were answered and understood, Ms. A’s daughter agreed that treatment with vasopressors would be futile, given her mother’s current condition. She then concurred that her mother should have comfort-care. No DNR consent was written during the hospital stay. Ms. A died that night.
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DISCUSSION
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This complex case illustrates a number of very significant bioethical issues that are commonly encountered in the psychiatric care of medically ill patients. The first and most important ethical issue involves the question of the use of surrogate decision-making. Ms. A was a 91-year-old woman with hypertension and diabetes mellitus, who was relatively well and living on her own with assistance from a visiting nurse and home attendant 4 hours daily. The history of present illness reveals medical and cognitive deterioration over a 6-week period before her hospital admission. The illness was never definitively diagnosed because Ms. A refused a full work-up for reversible causes of dyspnea and pedal edema. Her primary physician made a presumptive diagnosis of congestive heart failure and prescribed furosemide. Ms. A had some improvement in pedal edema but no improvement in cognitive functioning. Collateral information from her daughter, son-in-law, primary physician, and visiting nurse revealed that Ms. A not only refused to have a definitive work-up, but also refused an increase in her home care.
Ms. A was then found in her home, hypotensive and hypothermic, by the visiting nurse. She was then taken to the nearest hospital, and we learn that this is a community hospital without a psychosomatic-medicine department. An ethical dispute between Ms. A’s daughter and her treating physicians centered on whether Ms. A had the capacity to refuse care, specifically, treatment with vasopressors. The dispute was also about whether Ms. A had an acute reversible condition such as urosepsis and should be treated over objection or had a medically futile condition and was dying and in need of comfort-care.
We will begin this discussion with a brief review of the concept of Advance Directives, the types of Advance Directives available, and the definitions of each directive that was alluded to in the case vignette.
Advance Directives are plans that an individual can make regarding future medical decisions if or when he or she is lacking in capacity to make decisions. Advance Directives for healthcare decisions may include, but are not limited to, healthcare proxies, Living Wills, consents for DNR, and medical durable powers of attorney. Advance Directives can be written as designations or instructions. Most Advance Directives do not require a lawyer or even a special form. Advance Directive forms are available and can be useful in providing and standardizing documentation. A patient must have capacity to execute an Advance Directive, although documentation of such capacity is not generally available.
A Healthcare Proxy is a document that designates a person whom the patient trusts to make healthcare decisions when he or she is unable to do so. The person designated is called the healthcare agent, whereas the person creating the Proxy is the principal, and the document itself is the Proxy. The patient must have capacity when this document is executed, as with an Advance Directive. The signing of a Healthcare Proxy should be the signal that a dialogue has taken place or will take place between the principal and the healthcare agent. The designation of an agent is only as useful as the level and extent of communication about advance directives. The Proxy designation remains in effect until it is revoked by the principal. A copy of a Healthcare Proxy is as good as the original. The Proxy does not go into effect until or unless the principal loses decisional capacity. It is merely a document that designates a person to make decisions. It does not specify any advance directives except for those placed in a space left for stating "My agent knows my wishes about artificial hydration and nutrition." A Healthcare Proxy is not an indication of incapacity. The empowerment of the healthcare agent to make decisions begins only if or when the principal loses capacity to make decisions.
The use of the Healthcare Proxy empowers individuals to retain autonomy and to ensure that their previously expressed wishes will be honored if or when they can no longer make decisions for themselves by transferring decision-making power to someone who will act according to their expressed wishes and values.
The Living Will is a document that codifies advance directives and can provide explicit instructions about health care; it is an "instructional Advance Directive." It also must be executed by an individual with capacity. It may or may not designate a representative and therefore can be useful for individuals who are without family or social support networks from which to choose a trusted individual to make decisions for them. It differs from a Healthcare Proxy because it provides explicit written directives about medical procedures and treatments and can list as many as an individual wishes. Having such a list can provide false reassurance that the document has covered all conceivable eventualities and may prevent thoughtful deliberation and ongoing dialogues about future care. It leaves less room for flexibility and thoughtful dialogues with both physicians and loved ones.
Do-Not-Resuscitate (DNR) or No Emergency CPR
Consent for DNR is an indication that no emergency CPR should be performed in the event of a cardiac arrest or respiratory failure.
A patient with capacity can decide on DNR or revoke a previous DNR consent at any time. A consent for DNR should have no implications except about DNR. It is not at all indicative of a desire for less aggressive treatment and is never an indication not to treat.
It does not imply a change in care of any kind beyond the rejection of resuscitation, but it empowers the patient to indicate how he or she would like to be treated in the event of cardiac or respiratory failure. It can be waived temporarily during an acute illness or perioperatively.
The issues involved in this case include commonly encountered misconceptions about Advance Directives and end-of-life care. "Advances in medical technology and practice have extended the human life span. As a result, opportunities and conflicts are emerging at the end of life...The unique skills, knowledge, and nurturance of physicians are extremely important in caring for the dying patient."5
The specific issues included misconceptions about Advance Directives, the meaning and implications of a DNR consent form, and the need to request a psychiatric consultation for determination of decision-making capacity. Since no lawyers are needed for the documentation of Advance Directives, it may be that some confusion around these issues arose as a result of an attorney’s presence and involvement at the time of documentation of Ms. A’s Advance Directives. Although the reason for the attorney’s involvement was the execution of her will, the Advance Directives were also executed when Ms. A’s will was drawn up.
Also, the initial request for a psychiatric consultation resulted from a dispute between the treating physicians and Ms. A’s daughter and son-in-law. Ms. A’s family disagreed with the treatment team about Ms. A’s capacity to refuse vasopressors and believed that a psychiatrist would resolve the dispute and find that Ms. A did not have the capacity to make decisions for herself. Psychosomatic-medicine psychiatrists are familiar with the concept of fluctuating decisional capacity. There was a lack of understanding on the part of the treating physicians that Ms. A could have fluctuating decisional capacity and might have had capacity when she was first admitted to the emergency room and transferred to the ICU. However, as her medical condition deteriorated, and her delirium worsened, she may have been unable to make decisions for herself regarding treatments, such as with vasopressors.
It is clear that the treatment team thought that Ms. A had capacity while she was alert and able to respond to questions, although a more thorough documentation of cognitive status with a standardized instrument might have been helpful in resolving this ambiguous case. The treating physicians transferred Ms. A to an ICU and made an initial attempt to aggressively diagnose and treat her acute condition. It is unclear why the treating physicians did not continue to establish a definitive diagnosis or to provide emergency treatment with vasopressors over Ms. A’s objection, given the grave nature of her condition upon admission. The treating physicians initially considered starting vasopressors but did not seem to consider the possibility that Ms. A had an acute and potentially reversible medical condition that might have constituted a medical emergency. At that point, a psychosomatic-medicine psychiatrist may have suggested meeting together with the family and the treating physicians to provide both information and comfort to the family, as well as to resolve the dispute.
Having a DNR is not an indication for withholding any other medical care not specific to resuscitation, including the use of vasopressors. Furthermore, the psychosomatic-medicine psychiatrist may have suggested invoking a dispute mediation process by obtaining an emergency ethics consultation or a dispute-mediation consultation. When there is a dispute about an ethical issue such as decisional capacity, a dispute mediation process can help resolve the dispute, as well as provide evidence to the family that a loved one’s care is being carefully considered.
After it was very clear that Ms. A was in a coma and unable to communicate her wishes, her daughter (the designated surrogate decision-maker) accepted Ms. A’s decision to forgo vasopressors as soon as she understood the implications of that decision. Physicians have an obligation to relieve pain and suffering and promote the dignity of dying patients in their care.6 Every individual should be presumed to have the capacity for decision-making and the right to self-determination unless clinically determined to lack these abilities. Every patient should be able to decide whether to go to a healthcare facility, whether to accept medical care, refuse procedures, or sign out against medical advice. When it appears to the treating physician that the patient is unable to understand or reason about his or her medical care, that physician can make a determination of decisional capacity. Any treating physician can make this determination, which is an assessment of the person’s capacity to understand, communicate, and reason about specific medical issues. Cognitive impairment such as that seen in dementia or delirium does not preclude decision-making. If an attending physician finds it difficult to make the determination in the face of cognitive impairment and/or other psychiatric disorders, then he or she can call upon a psychosomatic-medicine psychiatrist to assist with this process.
In the case of Ms. A, the emergent nature of her medical condition and the possibility of her having an acute reversible condition such as urosepsis were not appreciated by her treating physician.
The reasons for this were never clear, but may have been multifactorial. The physicians may have been intimidated by the Advance Directives, may have inappropriately used Ms. A’s age as an indication of medical futility, and may have taken her refusal at face value, without considering the possibility of fluctuating decisional capacity in a person with many reasons for delirium. The end result was the lack of an effort to treat over objection, to establish a "potentially-reversible" diagnosis, and to resolve the dispute between the family and the physicians.
The strong emotions and sense of helplessness engendered in the family faced with decisions at the end of the life of a loved one may contribute immeasurably to the suffering of the family. An understanding medical staff and a psychosomatic-medicine psychiatrist can provide a modicum of consolation at this difficult time and help patients, families, and themselves untangle the web of ethical knots sometimes encountered.
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REFERENCES
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- In re Quinlan, 70 NJ 10, 355 A2d 647, cert denied, 429 US 922 (1976)
- Cruzan v Director, Missouri Department of Health, 110 S Ct 284 (1990)
- Kaplan SH, Greenfield S, Gandek B, et al: Ann Intern Med 1996: 124:497-504
- Omnibus Budget Reconciliation Act of 1990, Pub. L. No. 101-508
- Cassem NH, Brendel RW: End of life issues: principles of care and ethics. In: Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF, eds. Massachusetts Handbook of General Hospital Psychiatry, 5th Edition. Philadelphia, PA: Mosby 2004; p. 365 (365-387)
- Council on Ethical and Judicial Affairs, American Medical Association. Decisions near the end of life. JAMA 1992; 267:2229–2233[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
