Clinical Geriatrics

To the Editor:

I read with interest your article in Clinical Geriatrics.1 I am a nephrologist at a suburban Philadelphia hospital, and I also chair the Ethics Committee. My question concerns an 82-year-old woman with chronic renal failure who for two years had refused dialysis and, in fact, told me not to mention the “D” [dialysis] word when she came for office visits. This woman had been a nurse and knew patients on dialysis, which I think influenced her thinking. Also, she had never told her family that she was seeing a nephrologist. She eventually became uremic, and in August of 2007 I admitted her to the hospital and arranged for hospice care.

When I returned to the hospital after a weekend, I learned that the patient was in the operating room having an access placed for dialysis. Apparently, a well-meaning nurse practitioner had talked her into renal replacement therapy. The rest of her life was a disaster. From nursing home to hospital and back. From sepsis, to Clostridium difficile colitis, to total colectomy, to bedbound, to decubiti, to septic shock, to death. She never returned home in her final eight months of life, was not ambulatory for her final six months of life, and died as a DNR after I called her family to tell them that she was dying.

My question is: Do you believe a patient who repeatedly says “no dialysis”? When, in a competent patient, is a “no” a “no”?

Charles R. Schleifer, MD, FACP
Department of Nephrology
Lankenau Hospital
Wynnewood, PA

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Reference

1. Lantz ML. Do-not-resuscitate orders: When the patient and family disagree. Clinical Geriatrics 2008;16(9):11-14.

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Dr. Lantz responds:

This case illustrates how the basic principles of medical ethics, including patient autonomy, beneficence, and nonmaleficence, may seem straightforward until they are tested in real-world clinical situations. Patients have the right to self-determination. In this case, a patient with the clear ability to make her own decisions chose to refuse dialysis. The straightforward answer is, “No means no.”1

However, competent adults have the right to change their minds. Patients may reconsider, talk to their families, accept some therapies, and refuse others.2 It is important to clarify whether the patient was in any way coerced, even if the staff involved felt they were acting in a benevolent manner. There is often a very fine line between respecting a patient’s right to make informed decisions and trying to convince her to accept an invasive therapy that she does not want.3 As physicians, we should pay attention to one of the oldest and probably wisest principles of care: “First, do no harm.”4

The use of a written advance directive placed in the patient’s record may have helped convey her wishes to other clinicians.1 Documentation of ongoing discussions about her treatment wishes in her record may have helped communicate her prior consistent pattern of decisions to others. It is also possible that the patient decided to try more aggressive therapy. Review of a complex case with the treatment team involved is often helpful as a means of education and staff support.

Melinda S. Lantz, MD
Chief of Geriatric Psychiatry
Beth Israel Medical Center
New York, NY

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References

1. Schwab AP. Formal and effective autonomy in healthcare. J Med Ethics 2006;32(10):575-579.

2. Winzelberg GS, Hanson LC, Tulsky JA. Beyond autonomy: Diversifying end-of-life decision-making approaches to serve patients and families. J Am Geriatr Soc 2005;53(6):1046-1050.

3. Pollard BJ. Autonomy and paternalism in medicine. Med J Aust 1993;159(11-12):797-802.