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Whether no means no.

Dr. D is an emergency physician in a large urban hospital. One relatively quite evening Mr. R, a thirty-two-year-old male, presents to the emergency department complaining of shortness of breath. The problem, as it develops, is a depressingly familiar one to Dr. D. Mr. R, known to be HIV positive, turns out to be having his first episode of pneumocystis pneumonia, an often fatal disease of AIDS patients. The episode, fortunately, appears at present to be a relatively mild one; his blood test shows his lung function is only moderately impaired.

When Dr.D begins to explain this, Mr. R insists that his friend Mr. U be brought into the emergency department to listen to the doctor. Dr. D goes over the condition and describes the appropriate treatment: IV antibiotics. When asked, Mr. R denies any drug allergies.

As they grapple with the news that Mr. R has now changed from being a patient with HIV to one with AIDS, Mr. R and Mr. U produce a living will and durable health care proxy form designating Mr. U as responsible for decisionmaking if Mr.R becomes incompetent. The living will forbids cardiopulmonary resuscitation and prohibits "under any circumstances" endotracheal intubation and respirator ventilation, along with numerous other measures.

Dr. D believes strongly in patient autonomy. He therefore assures Mr. R and Mr. U that Mr.R's wishes, as clearly expressed, will be respected. After arranging for the papers to be copied and placed in the chart, he goes to admit Mr. R and Mr. U leaves.

While a bed is being readied, Dr. D orders a dose of the appropriate antibiotic to be given to Mr. R and goes to see the next patient. Upon starting the antibiotic and leaving the room for a few minutes, the nurse returns to find Mr. R unresponsive, with a bright red rash and severe trouble breathing. Immediately recognizing a life-threatening allergic reaction, she stops the antibiotic and calls for the doctor.

Mr. R is in anaphylactic shock. Quickly ordering the four appropriate medications, Dr.D opens his mouth to ask for an endotracheal tube and respirator--and realizes he has a problem.

Mr. R will die as his airway closes up if patency is not immediately ensured by placement of a tube. Indeed, in a case like this, placement often requires cutting the patient's throat to maintain the rapidly narrowing airway. Seconds, quite literally, count. The good news is that this is a time-limited condition. With immediate aggressive action, only a few hours or days of ventilator support should be necessary and there should be absolutely no long-term sequelae. Of course, it is possible that Mr. R's pneumonia will acutely worsen. He might then be unable to be weaned off the respirator. An emergency physician with no experience in the long-term management of either pneumocystis pneumonia or anaphylaxis, he is unsure of the chances of that.

What should Dr. D do?
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Title Annotation:Case Studies
Author:Silverman, Lewis M.; Dennis, Manette; Rouse, Fenella; Smith, David A.
Publication:The Hastings Center Report
Date:May 1, 1992
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