Tuesday, December 28, 2004

Substituted decision making, with clam juice.

Last year, I approached my hospital's Ethics Committee following a heated debate with nursing staff and administrators. The dilemma involved an older woman with an unusual sort of mental illness-- one which, when treated with a simple medication, was almost undetectable, but which left her entirely disabled (ranting, spitting, screaming) when untreated. She was brought in by police in the latter state, after running out of meds for a few days. She was unable to recognize what had happened to her, and adamantly refused to resume her medications. She threw food, ran naked in the hallways, refused to bathe.

A family member had years ago been appointed by the courts as this patient's legal guardian, empowered to make all health care decisions. The guardian implored me to resume Medication X at once, noting that this had always returned the patient to normal within days. Unfortunately, Medication X comes only as pills and syrup-- which (unlike injections) are virtually impossible to administer to a person who doesn't want to ingest them. So the guardian requested we use the syrup, dissolved in juice or soda, to provide treatment without the patient's awareness. Weighing the alternatives-- doing nothing, or forcible injection of a less appropriate medication-- I agreed. However, nursing staff refused, stating they could not deceive the patient. Next stop, the Ethics Committee.

I felt that the guardian had the full legal and ethical right-- perhaps even responsibility-- to make this request. His ward was languishing, suffering needlessly, endangering herself, and unable to make remotely rational decisions regarding her care. The guardian, who also testified before the committee, wished to provide the most effective and least invasive possible treatment. He had weighed the potential risks of being less than fully open with his ward, and found them far outweighed by the benefits. I argued that, ethically, the case was little different from a parent with a critically ill three-year-old who refused his antibiotic syrup. No one would question the mom's ethics if she quietly put the syrup in Orangina, if that's what it took.

Ultimately, though, the committee disagreed with us. They determined that it was unethical to give anyone medication without full disclosure--even when that person had a guardian making the decisions. In effect, the committee felt that it was preferable to do nothing, or to use painful but obvious injections using sub-optimal medication. Shortly thereafter, all staff received a memo from the chief administrator of the hospital, stating that it was henceforth forbidden to give any patient any medication without that patient's knowledge, at any time, for any reason. I immediately wondered what we should do with a patient who was unconscious and needed medication. But I chose to keep my mouth shut.

Eventually, after many days in the hospital, the patient agreed to resume Medication X. Within 48 hours she transformed into a completely different person. Although exhausted from her ordeal, she was conversant, coherent, delightful. She showered and did her laundry and asked after her community commitments. I discussed with her at length what had happened, of which she had little memory. I asked her what we could have done to help her faster-- "You should've put Medication X in a ginger ale and given it to me," she said unequivocally.

This week, my dear old cat, a big ex-stray, had to begin taking thyroid medication. He is my ward, because my brain is bigger and works more logically. But he resolutely does not want to take medication. I abandoned one previous round of medication-giving, two years ago, after many days of restraining, scratching, howling, clamped jaws, and a pet who ran from me every time I came home from work. This time around was no better-- however, it seemed more critical to succeed. So last night I crushed up his pill, and kneaded it into a mini-croquette using soft kitty treats and clam juice. Even before I was done molding it, he was pacing in front of me, demanding to have it NOW. I placed the morsel in his bowl and he gobbled it up. Then asked for another. Then he jumped in my lap and purred. Then we cuddled in bed, him happy with clams in the tummy, me happy that his thyroid was going to get better.

I think there's a moral here somewhere.


Blogger Karin said...

Thanks for the welcoming note... I'm struggling to get the picture uploaded, and furthermore I should be focusing on a paper, not this blog. I will soon be more active in my role as blogger. If I can get this thing figured out. (Website was much easier!)

But thanks anyway!

12/28/04, 4:17 PM  
Anonymous Anonymous said...

Turbo: I like your blog and hope you'll keep posting. You have an unusually quirky mind, which is entertaining and always interesting.
It seems that the guardian/ward set-up would make this a cut-and-dried case for going with the guardian's wishes to preserve ward's safety here, and the analogy with your cat is apt. But harder are the dilemmas posed by those who aren't wards but are just as disabled: a friend's sister who's schizophrenic and continually gets pregnant, with the friend's family ending up having to care for the kids or the kids being given away for adoption. There is no way anyone can get this woman to use birth control.
Another friend told me about a grossly obese woman living in a halfway house, and the staff can't limit her food-intake, despite doctor's orders. Everyone just has to stand by and watch her endanger herself.
You must see this kind of thing all the time, and it must be so frustrating.
Now, I want credit for this empathy, but there's no way to get it with your type of comment set-up (I don't want to sign up for all the "services" I think I'll get tied into if I give a password, etc.). So I'll just issue a clue (pssst: ML). To embed it properly as text, I'm just writing on here. Dum dee dum.
Thanks for the good blog. Over and out.

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