Follow-up: should the elderly woman have been put on a ventilator against her wishes?
Meenal and Bashir Mamdani
We would like to provide follow up and comment on the case study regarding putting a patient on the ventilator against her wishes (1).The dilemma that the daughter and son-in-law, both physicians, had faced was the decision to place this patient on a ventilator despite her repeatedly expressed abhorrence for such a treatment. They asked her at the time that she was gravely ill, hypoxic but seemingly in possession of her faculties if she still held the same views or if she now felt that she would agree to a ventilator if the hospital doctors advised it. She changed her mind and said that she would be willing to abide by the decision of the hospital doctors, including a ventilator if needed. Accordingly she was taken to a tertiary care hospital where she was admitted to ICU, placed on a ventilator for three days and weaned successfully to make a complete recovery. She returned to her activities of daily living in a short time. Surprisingly, she later told her relatives that she had no recollection of the conversation where she changed her earlier decision of refusing ventilator under any circumstances and again exhorted them never to put her on the ventilator again.
The ethicists would say that the relatives did the right thing in asking her again if she wanted to change her earlier decision. The patient in full possession of his faculties has the right to change his mind even after a “Living Will” declining ventilator etc has been made and submitted to the doctor and the hospital. However, an ethically correct decision does not guarantee a good outcome. In her case, the ethically correct decision turned out to be the correct medical decision also but that may not happen in every instance. She could have died a lingering and painful death after being on the ventilator for several days. Would we then have felt as confident of the ethics of asking her if she had changed her mind? Would we have wondered if we made a mistake in asking such a question of a person who was hypoxic and encephalopathic and perhaps not able to make decisions? As it turned out later she must have been encephalopathic as she had no recollection of making the decision to go to the hospital and on a ventilator and has only vague memories of the first day in the hospital. Surely, the bad outcome would have made us doubt the wisdom and ethics of asking such a question of a person who may not have been medically fit to answer.
What one learns from this case is that there are grey areas in ethical decision making as there are in medical decision making and as often happens, it is the outcome of a situation that allows us to either pat ourselves on the back or kick ourselves in the rear. As physicians we would like to spot clues that will help us make the right decision, both ethically and medically, before the outcome becomes known. For only then can we offer sound advice and make medicine more a science than mere inspired guesswork.