About one week ago a patient of mine was admitted to the ICU after being involved in a PVA train accident. Nobody is quite sure what happened to the patient, whether he was thrown out of a train, pushed or jumped out of a train. It is doubtful that the train hit him or he would most likely be dead.
The patient sustained multiple facial lacerations, traumatic brain injury, first rib fracture, nasal bone and septum fracture, left scapula fracture and right basal lobe atelectasis. The patient was intubated due to a low GCS scale (8/15).
When I initially started treating the patient, he was on a ventilator setting of CPAP, he had no spontaneous movement except for his eyes fluttering open at random times, he could not follow instructions or do any active movements. There was no social history in his folder, nobody came to visit him and there was no contact number of anyone who was his next of kin.
This patient may never be the same due to his brain injuries and we have no idea what his wishes were if he was ever in an accident; would he want to be resuscitated, put on a ventilator, or would he prefer to die. We may only discover what the answers to these questions are once he wakes up and can communicate, but what if we went against his wishes and kept him alive via a ventilator.
According to (HPCSA, 2008) in emergencies where medical personnel cannot obtain a patient’s consent, they are required to treat the patient in order to/with the intention of saving the patient’s life or avoiding deterioration as much as possible. According to (Selde, 2015), if a patient lacks the capacity to make an informed decision e.g. due lack of consciousness, then medical staff must act in the best interest of the patient. When medical staff is unsure about the patient’s wishes to not be resuscitated, they are encouraged to act under the principle of beneficence and provide full treatment and resuscitation to the patient. My patient was granted this, as his life was saved/ preserved and he is now on a ventilator trying to recover.
If the patient does have a spouse or family member he confides in, he may have told the person that if anything were to happen, he did not want to be resuscitated. If this were the case the medical practitioner attending to him needed to check the validity and /applicability of the DNR (do not resuscitate) orders (Selde, 2015) if it was given to them by the patient’s power of attorney (family member). If the power of attorney/next of kin decided to convey and honour the DNR wishes by refusing treatment, the medical practitioners (ideally the Drs) needs to inform the person of the implications of their decision in order for them to make an informed decision (Selde, 2015) about their loved one. Although it is unlikely that the patient had a loved one on scene when the accident happen, as they would have visited him by now or contacted the hospital or possibly even accompanied him to hospital on the day of his accident and the DNR would have been noted in his folder or put at the patient’s bedside.
If this patient were to make the decisions himself and not have the option of anybody speak/ act on his behalf, then as soon as the patient has recovered sufficiently to understand and comprehend the situation and what has happened to him/her, the medical personnel must explain to the patient what has been done to them and why (HPCSA, 2008). If the patient understands the situation and then refuses further treatment or any further advancement of treatment, this decision must then be respected and honoured by the health care practitioner (HPCSA, 2008). My patient has not yet reached this stage but at least there is an option for him in the matter/situation, if the medical staff did indeed go against his wishes, as his life was saved but we are not sure whether he wanted to be saved or not. None of this would be a problem if he did indeed want his life preserved and was content with being on a ventilator.
On the other hand, what if he knew what he wanted, if he ever needed to be resuscitated but never told anybody. What if he was homeless and did not have any relatives or loved ones to convey his wishes to. In a situation like this, with so much uncertainty whilst the patient is unconscious, I think it is a difficult decision to make when you are the first responder, as you do not know the person’s dying wishes. You would ideally like to honour their wishes but also need to do what is best for the patient in that moment. I think the medical professionals did what they could and acted in the patient’s best interests at that particular time, which is one of their main aims as medical professionals.
References
n.a. (2008, May). Seeking patients’ informed consent:The ethical considerations. Retrieved May 23, 2019, from The Health Profession Council of South Africa: https://www.hpcsa.co.za
Selde, W. (2015). Know when & how your patient can legally refuse care. Journal of emergency medical services , 1-3.
2 thoughts on “To treat or not to treat”
Hey, Zara thank you for sharing this writing it is very comprehensible and informative. I have not yet had the opportunity to work with patients who are ventilated but I can relate to your experience because I have treated patients with traumatic brain injuries who are unable to give consent or understand what is happening to them.
The content of your writing is aligned with the ethics module. The topic of patient consent is well expressed in your writing. I think it is well explained what and why the proceedings take place if the patient can not give consent. A suggestion I would like to make regarding your content is that you add your own opinion and feelings of the experience.
The arguments in the content are well-expressed and substantiated by literature. I like how you presented the argument of a situation whereby the patient would have preferred to be left to die rather than intubated. You substantiated appropriately with literature
The intext references are correctly formatted. Consider revising the first reference in your bibliography.
In terms of grammar and spelling make the following changes (Paragraph=P, Line= L);
P2L1: nasal bone and septum fracture……= replace and with a comma
P5L3: due lack of consciousness= due ‘to’ lack of consciousness
P6L7: happen=happend
P7L5: in that moment = at that moment
Hi Zara
Thank you for sharing your piece. I can somewhat relate to what you are saying here, as I have also worked in the ICU previously.
The content in the writing reflect patient consent to treatment, which is part of topics covered in the content of the module. You explain well what patient consent is and how it can affect the patient if the patient is not able to give consent or not. You also somewhat touch on another topic in class which was on living will, if the patient wants to be resuscitated or not, the wishes of the patient, and who the patient would like to have in charge of his/her medical decisions if they cannot do it for themselves.
You have given a detailed explanation on your own clinical practice experience. You explained how the patient presented and why he could not give consent. A suggestion here would be to explain how you felt, what went through your mind and why this event was so significant for you to write about it. As well as to make it more impactful to the reader on why this topic is important, and why they should pay attention to it.
I would like to make a suggestion about the picture that you have used. I would suggest that you make use of a picture that shows the ventilator, as well as all the drips and lines certain patients are lying with, especially after what your patient went through. In my opinion the picture does not do justice to how patients look when they are in the ICU after such an accident. Finding a picture that accurately portrays how patients look in the ICU will make your piece more relatable.
The evidence you have presented in your writing pieces support the claims you have made about the medical staff making the decisions if the patient cannot decide or if there is no next of kin. You also support the claim you make about the patient making decisions when/if he/she wakes up. If possible you can add another reference or two, to add to the reliability (what other sources say about your topic, for example arguments for and against the claims you make) of your writing piece.
Your piece consist of many paragraphs which makes it easier to read and follow.
In the first three paragraphs you make use of a few abbreviations. Write out what each abbreviation means as if the person reading this piece does not know what it means.
The first sentence in the fourth paragraph can be made into two sentences so that it is easier to read. For example: “This patient may never be the same due to his brain injuries and we have no idea what his wishes is/were. We do not know if he ever wanted to be resuscitated, put on a ventilator, or preferred to die in a situation like this.” Also take note of the above grammar/spelling corrections Mfundo made, as I have also noted the same things.
I hope the comments i made is clear and that you understand it. All the best with the final submission.