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"Make me live": autonomy and terminal illness.

"Make Me Live": Autonomy and Terminal Illness

Discussions of terminal care are always difficult, even with a patient with whom one has a long-standing relationship. In this case the attending physician must make a decision about life-prolonging treatment in a patient he has never seen before and who has consistently dealt with her illness with anger and denial. What can the attending do to gain the trust and confidence of this patient? To talk of respirators and endotracheal tubes would do little but add to the patient's anxiety. Nevertheless, a decision must be made about a DNR order. Authoritative sources insist that the patient has the right to participate in this decision. What should a virtuous physician do?

Before analyzing the ethical issues, it is first necessary to be clear about the medical facts. I shall assume that this patient is indeed terminal and that no therapy exists that would alter the progression of her cancer. The patient's shortness of breath could potentially be relieved (at least temporarily) by removal of fluid from her pleural space. Several attempts at thoracentesis have failed, however, suggesting that either there is very little fluid in the pleural space or that it is inaccessible due to the large amount of tumor in the patient's chest. Either explanation would decrease the likelihood that thoracentesis would provide much relief and increase the likelihood of pneumothorax (accidentally nicking the lung while attempting to remove the fluid). Since the patient's respiratory status is already compromised, a pneumothorax would likely cause a respiratory arrest requiring that the patient be placed on a respirator and taken to the intensive care unit. Since nothing can be done to reverse progression of the cancer, the patient would remain on the respirator indefinitely until the tumor destroyed so much lung that it would technically be impossible to ventilate her.

Given the possibility of an impending respiratory arrest, it would be ethically unacceptable for the attending physician to proceed with thoracentesis without considering a DNR order. To subject MG to the violence of a resuscitation without her knowledge and consent would be completely wrong. Although most patients would prefer a quick death to a prolonged and agonizing one, this is not invariably the case. The religious convictions of some patients require maintenance of biological life as long as technically possible, while others belive that suffering the agonies of death leads to ultimate salvation. A few days of extra life, even on a respirator, may permit a patient to meet a desired goal such as disposal of personal property or knowledge of the birth of a grandchild. It is for the patient and not the physician to decide if achievement of these goals is worth suffering one's last days attached to a respirator. A patient's autonomous choice should be respected. However, autonomous choice means that the patient understands the nature of the therapy she is requesting and its likely consequences. For a dying patient to demand

"Do everything to make me live" is panic, not autonomy. MG has never accepted her terminal illness and that the best that medicine could offer her was comfort care. An autonomous choice is also one made from available options. "Life," in a meaningful sense of the word, is regrettably not an option available to MG.

The attending might be tempted to write a DNR order unilaterally on the grounds that resuscitation is futile and that he is acting as a beneficent physician by allowing his patient to die in peace. Indeed, until recently, it would have been considered unethical for a physician even to tell a dying patient that she is actually dying. This is the therapeutic privilege that can be traced back to Hippocratic writings and was firmly established by Percival in his Medical Ethics of 1803. Until recently, a physician could actually do little except to provide comfort, so whether patients understood the nature of their illnesses or not was irrelevant.

Now, meaningful choices can be made, so it is important that patients understand the nature of their illnesses and alternative therapies. The paternalism characteristic of the ethics of previous generations would never be tolerated by today's well-educated and consumer-oriented patients. Even with respect to writing a DNR order, we recognize that a patient has a "right to know."

What should the physician do? The attending physician must return to his patient and again attempt to engage her in a discussion of her care. He should explain gently, as the resident had previously, that they can do nothing to reverse her cancer but that they would attempt to relieve her shortness of breath by removing pleural fluid. He must assure MG that he will provide whatever is necessary to ease her anxiety and relieve her pain and ask her if she has any questions or has anything else on her mind that she wants to discuss. He should then step back and wait. He ought not to push the patient into a discussion of her impending death. A "right to know" does not mean a "duty to know." If MG remains silent, he should write the DNR order without further discussion. Not to do so would run the risk of subjecting the patient to an unwarranted resuscitation. To insist that this dying patient discuss the time and nature of her death simply for the sake of "autonomy" would be unspeakably cruel and contrary to the physician's primary directive of "do no harm."
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Title Annotation:case study with two opposing commentaries
Author:Misbin, Robert I.; Milller, David H.
Publication:The Hastings Center Report
Date:Sep 1, 1990
Words:905
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