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A Patient With Acute Traumatic Quadriplegia Who Requested a DNR Order

Received April 13, 2007; revised June 18, 2007; accepted June 21, 2007. From the Dept. of Psychiatry and Human Behavior, Jefferson Medical College, Philadelphia, PA. Send correspondence and reprint requests to Dr. Field, Consultation–Liaison Division, Dept. of Psychiatry, Suite1652, 1020 Sansom Street, Philadelphia, PA 19107-5004. e-mail: howard.field{at}jefferson.edu
© 2008 The Academy of Psychosomatic Medicine

Key Words: DNR • Spinal Cord Injury • Right-to-Die

INTRODUCTION

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As patients have become increasingly empowered to determine their treatment,^1,2 physicians have altered their rationale for challenging those patients’ decisions that they deem to be unwise, moving from a stance of superior wisdom to questioning the patient’s mental ability to understand and decide. Along with these changes has been a shift in the legal and ethical burden from attending physician to psychiatric consultant. This is, as one might imagine, a burden not welcomed by many consultants.³

In acute trauma, determination of decisional capacity can be especially problematic. Exemplifying this difficulty is the demand by a patient with acute high spinal cord injury (SCI) to refuse resuscitation or even to discontinue life-support measures. There are few patients more disturbing to hospital staff. Although the physician, for internal and external reasons, may accede to the patient’s demand,⁴ the opposite response occurs more often. Because these patients are often young, doctors and nurses feel that there is much meaningful life to be preserved after the trauma, and they are reluctant to give up the struggle. Often, the physician, attempting to get the patient to reconsider, enlists family, clergy, and social case-worker to dissuade—some would say manipulate—the patient. Failing in this, the attending physician turns to the psychiatrist to determine whether the patient has the mental capacity to understand and make such a serious decision.

Case Report

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A college student, crossing the street in front of a stopped bus, was struck by a passing automobile. She was conscious and immediately aware that she could not move. Emergency room personnel found the patient to be diaphoretic, breathing shallowly, and with no motor or sensory function below the neck. A spine film showed a severe displaced fracture of C-4. The usual treatment for such injuries was done in exemplary fashion; immobilization, tracheostomy and ventilation, lines, J-tube, Foley catheter, head CT scan to rule out intracranial damage, and, later, anterior–posterior cervical fusion. The patient also had common complications of this injury: aspiration pneumonia, urinary tract infections, and septicemia, all treated vigorously. Her physicians were very eager to wean her from the ventilator, but each attempt resulted in desaturation, with noisy monitor signals and the need to be reconnected—events that were very distressing to the patient. While in critical care, she expressed the thought that she would be "better off dead." Her caregivers felt that she was depressed and started her on one of the antidepressants available at the time, amitriptyline. Even after transfer to the rehabilitation unit, she had to return to a medical floor for further treatment of complications. Finally, 4 months after her injury, afebrile and able to breath independently, she again went into rehabilitation. There, she announced firmly that she wished no further "codes," no antibiotics, and, indeed, no further medical treatment of any kind. It was not clear how much the attending physician discussed her decision with the patient, but a psychiatric consultation requesting competency determination quickly followed.

The Psychiatry consultant found the patient restlessly waiting. She spoke softly but clearly. She stated that she knew the law, was of age, understood the nature of her condition and what would happen if she became unable to breathe without ventilation or infected without antibiotic treatment. She wished no resuscitation and no antibiotics. On examination, there was no evidence of thought disorder, cognitive impairment, or symptoms of posttraumatic stress disorder (PTSD) connected to her injury. Before the injury, she had been an athlete and an accomplished musician. She did not wish to live as she had been living over the past few months. Her affect, hostile at first, became appropriately sad when discussing her losses; however the depressed mood was not pervasive. Although the consultant declared her incapable of medical decisions because depression impaired her judgment, this diagnosis may have been more convenient than accurate.

Although it has not discussed in the literature, physicians, in uncertain clinical situations, have increasingly come to depend on an official diagnosis to justify opinions of impaired capacity. It may be impossible to make a DSM diagnosis of Major Depression or Depression, Not Otherwise Specified, in an acute high SCI patient.⁵ Sleep disturbance, appetite disturbance, weight loss, psychomotor retardation, fatigue, and diminished interest accompany the injury and the environment in which it is treated. How does one measure self-esteem in a patient who has lost many of the attributes that contributed to positive self-esteem? This patient did not appear indecisive and gave no expressions of guilt. She was obviously in a state of mourning; however, mourning for loss of self or a part thereof has no place in the current restrictive diagnostic schema because the term bereavement is confined to loss of other.⁶ Thus, the psychiatrist’s opinion on incapacity seems to be without anchor in an official diagnosis.

Several psychiatrists observing the process disputed the determination, feeling that "impaired capacity" could never be justified in a cognitively clear patient in the absence of a clear diagnosis of psychosis or major depression. To them, such criteria as hopelessness or demoralization were judged to be ill-defined, inadequate reasons to curtail a patient’s autonomy. The patient was understandably infuriated by the implied insult to her intellect. By declaring her incompetent, the consultant had removed the last support to her self-esteem. The ensuing crisis was handled with remarkable tact and honesty by the staff. Some of the personnel sympathized with the patient’s distress; others, with the patient’s wishes. One even offered to help find legal counsel. Nevertheless, she did not pursue legal avenues to dispute the determination, and, as her respiration became more secure, her demands to die receded. With an increased sense of empowerment, increasingly positive feelings toward the rehabilitation personnel, and continued love and acceptance from family and friends, she continued with rehabilitation. After discharge, she furthered her education and found a significant career and relationships.

Discussion

TOP INTRODUCTION Case Report Discussion REFERENCES

 
Psychiatric consultants have wrestled endlessly with the issue of patients’ mental capacity to make medical decisions. Although the President’s Commission on Ethics insisted that the decision about competency is "not a medical or psychiatric diagnostic category: it rests on a judgment of the type that an informed layperson might make,"⁷ this notion seems unrealistic.

Early consultants were satisfied with a global examination that yielded a subjective impression, all-too-often based on the patient’s doing whatever the attending doctor wished. In the era of increasing patient rights, court decisions slapped down presumption of incompetence in the absence of concrete evidence. Consultants then borrowed from the standard legal boiler-plate of civil and criminal law criteria; the patient’s awareness of the nature of the illness, the proposed treatment and alternatives, the risks and benefits of these, and the ability to communicate choice. The objective model, requiring reasonableness of decision and requirements for rationality,⁸ raised the hackles of ethicists,⁹ and so there was a conflict between autonomy and beneficence.

Several writers advanced the concept of a "risk–benefit sliding scale," with strict criteria for grave decisions and relaxed criteria for trivial ones.^10,11 This formula did not elicit universal approval, since decisions as to seriousness or risk-versus-benefit remained out of the patient’s hands, dependent on the judgment of the caregiver.¹² Other writers cautioned that merely being able to name the illness was insufficient; the patient should understand the relevant information about diagnosis, treatment, and the nature of the illness; appreciate the current clinical situation; and be able to manipulate this understanding rationally.¹³ Decisions should be consistent with the patient’s value system and life goals. A number of workers found subtle psychopathology that could interfere with judgment, such as the glib-but-distrustful paranoid personality, depression, hypomanic denial, severe obsessionality, and hopelessness.^14–16 One writer found evidence of impaired cognition in all seriously ill patients.¹⁷

To help in the clinical situation, workers turned to standardized instruments, beginning with structured interviews. A recent article reviewed 22 different instruments for evaluating competency.¹⁸ Probably, the best known and standardized of these is the MacArthur Competence Assessment Tool–Treatment (MacCAT–T).¹⁹ Many of the instruments reviewed involved consent to psychiatric treatment or participation in research and were less applicable to acute medical illness. Some were lengthy, rendering them impractical in emergency situations.

In acute SCI, the situation may be even more difficult. Authors have expressed the opinion that the patient with high SCI is incapable of participating in medical decisions for up to 2 years after injury.²⁰ Despite ethical objections to the undefined duration of the "incompetent" state, there are many factors that might disable the acute patient’s decisional capacity for some period of time. The cognitive and affective effects of the physiologic and psychic upheaval after acute trauma, hypoxia, and surgical intervention are known. Stress hormones are known to alter mood, cognition, and memory. Encephalopathy resulting from cytokine storms may affect judgment. The trauma of the injury and ensuing disability may be a source of PTSD. Also, it may be impossible for the patient to realize what life as a quadriplegic might be like until after rehabilitation.

Decisions to discontinue life support in acute trauma make for painful clinical decisions and difficult competency determinations. The consultant may find no comfort in appeal to the usual categorical or diagnostic lists, but instead must take time for a careful exploration of motivation, life history, and value systems of the patient and also the physician’s own values, motivation, and previous experiences. This process cannot be compressed into the brief time usually allowed for competency determinations. A solution to the quandary might be to apply a sliding-scale concept to acuteness as well as to the seriousness of a clinical crisis. It is one thing for a patient who has suffered over a period of time to insist on removal of life support but quite another to make that decision in the brief moment after an acute trauma such as high spinal cord injury. In acute trauma, where the patient’s life has changed so suddenly and so profoundly, one may justify a pause sufficient for the patient to learn what might be expected of future life and for the consultant to understand the meaning of the ultimate request. As in the present case, recurrent acute complications may further lengthen the time required for an informed decision. Medicine has discarded its old, discredited authoritarianism, but one may wonder whether this trend has gone too far. It may be more ethical for the physician not to abdicate responsibility in a relationship of asymmetrical power and knowledge. The greater experience and knowledge of the physician may confer privilege as well as responsibility. One positive development for the physician in this difficult position is the increased availability of an ethics consultation from a medical ethicist or ethics committee: in guarding against the physician’s subjectivity, there may be strength in numbers.

Conceptions of capacity to give consent are still evolving. Workers in the area appear to be taking two equally-valid paths. On one hand, there is an effort to increase the validity of assessment, using protocols with arithmetical scoring, evaluated for reliability. On the other hand is a trend toward dealing with patients’ requests in a more dynamic manner, at times as education, interpersonal interaction, or psychotherapeutic process. The Psychiatry consultant should endeavor to focus on the person rather than diagnosis, and resist the often-enormous pressure to rush, taking sufficient time to understand the whole patient and circumstance, and turn for aid to ethicists or an ethics committee. We should be aware that the difficulties in determining competency in unclear cases reflect turmoil in the underlying value systems now engaging our society as a whole. We have not heard the end of this dialogue between autonomy and beneficence.

REFERENCES

TOP INTRODUCTION Case Report Discussion REFERENCES

 

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