What should the care team at the emergency room do?

Ethics Committee Case Study

John, a 32 year-old lawyer, had worried for several years about developing Huntington’s chorea, a neurological disorder that appears in a person’s 30s or 40s, bringing rapid uncontrollable twitching and contractions and progressive, irreversible dementia. It leads to death in about 10 years. John’s mother died from this disease. Huntington’s is autosomal dominant and afflicts 50% of an affected parent’s offspring. John had indicated too many people that he would prefer to die rather than to live and die as his mother had. He was anxious, drank heavily, and had intermittent depression, for which he saw a psychiatrist.  Nevertheless, he was still a productive lawyer. John first noticed facial twitching three months ago and two neurologists independently confirmed a diagnosis of Huntington’s. He explained his situation to his psychiatrist and requested help committing suicide. When the psychiatrist refused, John reassured him that he did not plan to attempt suicide any time soon. However, when he went home, John pinned a note to his shirt to explain his actions and to refuse any medical assistance that might be offered, then, ingested all of his antidepressant medication.  His wife, who did not yet know about his diagnosis, found him unconscious and rushed him to the emergency room without removing the note.

• What should the care team at the emergency room do?
• Discuss this question using the following topics and analyzing how these issues are applied to the decision made by the emergency room care team. Use at least two scholarly sources to support your discussion. Your initial post should be a minimum of 250 words.
• Review of the topics within this case:
  • Medical Indications: There are two diagnoses/prognoses that merit consideration. The underlying chronic disease of Huntington’s has no available treatment and a bleak long term prognosis. However, there are effective treatments available for the acute diagnosis of drug overdose.
    • How does the chronic diagnosis affect the team’s response to the acute condition?
  • Patient Preferences: We know from the patient’s suicide note that he is refusing all medical treatment. However, what do we know about these statements of preference?
    • Were they informed?
    • Was the patient competent to make that decision?
  • The answers to these questions remain unclear, but we do know that the patient does not have decision making capacity for the present decision of whether to proceed with the gastric emptying.
    • Is there a surrogate decision- maker available?
  • Quality of Life: Life with Huntington’s can be difficult with the onset of spasms and dementia. John was familiar with the quality of life associated with living with Huntington’s as he watched his mother die of this disease. On the other hand, John does have a supportive family and continues to be able to work for the time being.
    • How should the diminished quality of life that is anticipated in the future affect the current decision?
  • Contextual Features: Several factors in the context of this case are significant. While the patient has a legal right to refuse treatment, he is currently unconscious and his surrogate (his wife) is requesting treatment. There are also certain emergency room obligations to treat emergent conditions.
    • How should the emergency staff weigh the various competing legal and regulatory duties?