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When Your Heart Says No but the Law Says Yes: The Unethical ICU Admission FREE TO VIEW

Ali Chaudhry*, MD; Seth Koenig, MD
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Hofstra-NorthShore LIJ, Manhasset, NY

Chest. 2012;142(4_MeetingAbstracts):358A. doi:10.1378/chest.1390653
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SESSION TYPE: Critical Care Student/Resident Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Often times critically ill patients are admitted to the ICU without known advance directives. These situations present unwarranted stress to the physicians, the family members and most importantly the patient themselves. Despite initiatives to promote discourse between physicians and patients, there still remains an inequity that needs to be further addressed.

CASE PRESENTATION: A 95 year old man who had a witnessed seizure at home was brought to the ED by his home health aide. She handed the ED with a copy of his advance directives which unambiguously declared he did not want to be intubated or resuscitated. The health aide verified that these were indeed his wishes. However, the ED called his daughter who was the health care proxy. She instructed the ED to intubate the patient who was subsequently admitted to the ICU. After discussion with the daughter, she stated she knew her father did not want to be intubated but was not comfortable making the decision. An EEG showed the patient suffered anoxic brain injury and had a poor prognosis. After this discussion, the family decided to withdraw care. The patient was extubated 5 days after admission and died hours later.

DISCUSSION: This case highlights the ethical dilemma that ICU physicians must often confront. From a medical ethics outlook, this circumstance presented an ethically inappropriate ICU admission as it violated all four principles of ethics. Firstly, patient autonomy was dishonored by the family who deliberately went against their father’s wishes. The notion of “primum non nocere” or “do no harm” was violated. Intubation and central line placement harmed the patient as the risks associated with these procedures outweighed any benefit this patient would receive. The notion of beneficence was violated as the physician did not act in the best interest of the patient. Finally distributive justice was violated as these resources should be allocated for a patient with a better prospect of recovery.

CONCLUSIONS: Physicians at times forget that they too have autonomy and I would argue it should be the fifth principle of medical ethics. The Texas Advance Directives Act allows physicians this opportunity. It allows the physician to dictate patient care in the best interest of the patient, not the best interest of the family, without fear of litigation. Ethical care is in the best interest of the patient and provides a cost effective approach to ICU care that should not be ignored.

1) none

DISCLOSURE: The following authors have nothing to disclose: Ali Chaudhry, Seth Koenig

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Hofstra-NorthShore LIJ, Manhasset, NY




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