Ethical Enigmas 5

Response to Enigma 5:

You are a surgical house officer. An 87 year old lady has been admitted with an acute abdomen. She is too frail for surgery and is for supportive treatment only. She has been put 'not for resuscitation'. She is currently comfortable and your consultant has asked you to prescribe an intravenous 24-hour pump containing a dose of opiates that is much too great for her needs. What are your options?

In dealing with this dilemma, you must consider both your responsibility to the patient and your relationship with your consultant. Although our first duty is to our patients, as Christians we must also respect those who have authority over us. However, we are not obliged to obey them if this would mean disobeying God (Acts 5:29).

Obviously one option would be to obey your consultant and prescribe the pump. I believe this would be wrong as high dose opiates could well lead to her untimely death, for which you would be responsible.

Other options would be: not to prescribe any opiates (eg morphine or diamorphine); to prescribe a lower dose of intravenous opiates, or to prescribe subcutaneous or intramuscular opiates on an 'as needed' basis. This would largely depend on the patient's condition. We are told that she is comfortable now, but we do not know how much and what form of analgesia has been required to achieve this.

The principle of 'double effect' is often raised in end-of-life scenarios such as that described above. This states that 'if measures taken to relieve physical or mental suffering cause the death of a patient, it is morally and legally acceptable provided the doctor's intention is to relieve the distress and not to kill the patient'. This is usually applied to the use of strong opiates to relieve pain in terminally ill patients, such as in our enigma. The difficulty of this principle is that the doctor's intention is not measurable. As Christians, we are accountable to God who knows all our thoughts and intentions. Therefore, in using such treatments we must ensure that our intention is to make patients more comfortable, accepting that as an unintended consequence, death may occur a little sooner. According to palliative care specialists, when used correctly, strong opiates shorten the life of only one in 1,000 patients; successful pain relief can extend life as appetite and wellbeing improve. There are, however, doctors who would prescribe a drug saying that their intention was to stop pain, but their real aim was to cause death. This may have been the intention of the consultant in our enigma and we need to be wary of the possible 'hidden agendas' of our colleagues and seniors. We must ensure that our intentions and prescribing decisions stand up to God's expectations of us.

Other aspects of the patient's care deserve mention. The decision not to operate should be considered; it may well be that this is appropriate, if the patient is unlikely to survive surgery. 'Do not resuscitate' decisions can be controversial but may be appropriate if resuscitation is unlikely to be successful, and would only lead to unnecessary trauma and loss of dignity. Since we do not know the cause of her acute abdomen, it is difficult to prognosticate. But it is possible that she may pull through without surgery, so she should be given every chance and I would argue in favour of intravenous fluids.

I return now to the relationship with your consultant. If you have decided that you are not happy to carry out his request, one option would be to do what you have decided without consulting him. This may well be an option if he disappears after the ward round, not to be seen for a few days. However, it would be more courteous to discuss it with him, explaining why you are not happy and what you would prefer to do. This takes courage and could be difficult. He may become angry but, on the other hand, he may respect you and see your point of view. Asking the hospital palliative care team to assess her needs is always a wise move.

It would be wise to discuss your feelings first with your registrar or SHO, especially as you are less experienced clinically. It may be that they will share your concerns. If so, you have a much stronger case, but if not, you will have to approach your consultant alone.

If he insists on this course of action, you should calmly state that you are still not prepared to do it. It may be that he will prescribe the drug himself, or ask another member of the firm to do so. If this happens, you may be powerless to change it. You could voice your concerns to the doctor prescribing but if it continues you will simply have to commit the situation to God in prayer.

Whatever happens, there are other ways in which you can show compassion to this lady. Because she is not an 'interesting surgical case', she may receive little attention on ward rounds. However, you can still make sure that she is treated with dignity, made as comfortable as possible, and that if she is conscious you talk to her. It is also important to communicate well with the relatives, if present.

Acknowledgement: Dr Roxana Whelan, GP in Nottingham, for the main text of this Enigma.

Enigma 6

A 35 year old man comes to see you and asks for diazepam tablets. He says he hasn't had a drink for 24 hours and is starting to feel rough. On questioning he admits to a bottle of vodka a day. He is unemployed and lives in a flat next door to a pub. How can you start to meet his needs?

Please email responses to john.wenham@tinyworld.co.uk