Ethical question: to tube or not to tube?

[Doczilla]

41 YO F presents to the ED in status epilepticus due to profound hypoglycemia. She has a history of type I diabetes as well as multiple sclerosis. She functions independently at home, but has maxed out therapy for the MS, which has been progressive.

The patient was last seen normal by her husband about 3 hours ago when he went out to run an errand. When he returned, he found her unconscious. Accucheck read "low", so he gave her 2mg of glucagon IM and called paramedics. Blood sugar done by EMS read 113, though we think this may have been a spurious reading by the meter. Nothing suspicious was found such as a suicide note or empty pill bottles.

She is on an insulin pump, which appears to be functioning well and is not empty. She gets 2mg ativan IV and D50, which stop the seizures. She never regains consciousness in the ER. In fact, she requires multiple doses of D50 and a D10 drip to maintain her blood sugar.

Here's the kicker: she has a DNR order, which the husband produces from 2007 (DNR orders in Ohio do not expire). He, and her father (both at the bedside), state that the patient had explicitly stated that she would not want mechanical ventilation, CPR, or defibrillation at any time, and was quite adamant about it. The DNR form does not specify what treatments can and cannot be performed, simply to not resuscitate in case of arrest. No mention on the standardized form about intubation or any other measures.

I'll tell you later about what happened with her.

I got into a discussion with a couple of the nurses about what to do with her. I did not think that intubation was appropriate, as we had an (albeit old) DNR form and two close family members that said she would not want it. The nurses said that she is young, still very functional and relatively healthy, so why would we not intubate or resuscitate her if needed? I cited two chronic, progressive, debilitating diseases, although I concede she is not bed bound or demented. They brought up the fact that the husband may be stretching the truth for his own purpose, i.e., to rid himself of her. They brought up the possibility that he may have given her an intentional OD of insulin, though at the present time there is no evidence of foul play. She is currently maximized on therapy for the MS, and in fact exceeding typical doses of her medication (not illicitly, but with doctor's order) to try to slow the progression.

So, if it is medically appropriate (i.e., for airway protection, need for ventilation) do you intubate her?

I am not concerned with discussing details of her treatment right now, only the ethical question of intubating or defibrillating her if it becomes necessary.

'zilla

[PedOncoDoc]

With a DNR order, and both her husband and father stating she would not want rescucitation, I would not intubate her. In fact, once the DNR order was produced, I feel it would be unethical - and possibly illegal - to intubate her.

I feel the nurses were out of line in making accusations of the husband (especially when the woman's father supported the decision as well) and made assumptions about the wife's quality of life.

So what happened?

[Red Flag 1]

Agreed.

[swatsurgeon]

No intubation for sure, as far as the nurse stating that she's young, etc, have her review the two cases of wrongful life: successful lawsuits against medical personnel that wrongfully resuscitated patients out of a paternalistic need to intervene when there were written advanced directives and orders to do no resuscitative maneuvers. Both were in the 10's of millions against the medical personnel/hospitals, etc., and in my opinion were appropriate lawsuits.

When faced with these issues, as long as no documentation is in evidence, do all appropriate medically indicated treatments, they can always be withdrawn when a durable DNR order is uncovered or an advanced directive is produced. The withholding or withdrawal of artificail medical support are one and the same as per the courts so not starting something or removing an intervention or therapy is viewed as the same and appropriate when orders exist to remove/stop/not initiate said therapy.

If she regains consciousness and says stop all Tx's, then make sure her family is at bedside so they see it and then document it and stop all Tx's....we do it all of the time.....and feel good about being able to follow the wishes of the patient, NOT the wishes of the family. It is always a matter between patient and physician, the family is hopefully representing the wishes of the patient, not their own.

ss

[Doc Diego]

Very unusual. Someone who faces their own mortality and quality of life issues head on and institutes a DNR order. Don't see that enough where I work(on an ambulance). Sounds like the nurses you work with are somewhat inexperienced (or love drama). A DNR is a DNR.

[JAGeorgia]

Disclaimer: I am not a attorney. This is not legal advice.

An Advance Directive is exactly that! It is not a Power of Attorney for medical treatment so the alleged motives of the husband/father are irrelavant.

Intubation/trach/cric to maintain an airway on a DNR patient? To what end? Find a manequin if you want to practice or spend time saving someone's life who wants to be saved. This lady MADE THE DECISSION. Have enough respect and honor to follow her wishes.

IMHO: It may not always be easy but it's right.