CorrEthics

By Michael T. Puerini, MD, CCHP-A and Dean P. Rieger, MD, MPH

Posted on March 3, 2010 – The Little Old Man Who Wouldn’t: Patient’s Autonomy vs. Safety

George Campbell (not his real name) is a 70-year-old mentally retarded male who has been institutionalized for the majority of his life. Currently housed at a DOC facility for setting fire to his prior place of residence, a group home, he had lived at the state “home” for the mentally retarded for over 50 years until it was closed by the state in 2001. Since that time he has lived at the State Hospital, in group homes, and in various prisons and jails.
He’s a cantankerous gent, is oppositional about most interventions (especially medical), and has admitted that his main goal is to get back to the State Hospital where the food is better. He seems to have a genuine fear of medical personnel that seems to be masked with belligerent or, at best, “ornery” behavior.
The patient has multiple medical problems, among them Morbid Obesity, severe Degenerative Arthritis, and Congestive Heart Failure. He spends most of his time in a wheelchair, walking rarely. While he is unsteady on his feet, he walks to the bathroom when he can do so unseen. He has had Venous Thromboses of his lower extremities on more than one occasion. He has been taking Coumadin regularly for this reason. In the past when the medication was withdrawn, he developed solid clinical evidence of recurrent acute venous thrombosis.
Mr. Campbell has been refusing to have his blood drawn for INR levels. On prior blood draws, when he agreed to the blood work, he had violently withdrawn his arm just at the time when the phlebotomist was inserting the needle.
On the day in question, a nurse locates a lovely vein, but he states that he will refuse the blood draw. The doctor is called to the area. While the doctor is talking to the patient, the nurse, having already prepped the site, quickly inserts the phlebotomy needle and, while another nurse holds the arm down “for safety”, withdraws the blood. The entire procedure takes about a minute. The patient was briefly unhappy and then switched to a different grievance with the health care team.
This episode, while commonplace in general content, is clearly uncommon in its outcome, with good reason. The nurse in question broke usual ethical protocol in that he chose to draw the blood when he saw his chance as the patient was distracted. The doctor denies any wrongdoing, saying that he had not arranged anything beforehand with the nurse. Respect for patient autonomy dictates that when a competent patient refuses a procedure, no matter how benign, that patient’s right to refusal should be honored. It could be argued that, in this case, the patient was unable to fully appreciate the risk of bleeding, disability, or even death associated with over-anticoagulation. The combination of mental retardation, gamesmanship, and patient anxiety all contributed to the likelihood of his being unable to make a rational decision in this case. Still, there is clear ethical reason not to sneak up on an unsuspecting patient with a phlebotomy needle. Two things are clear. One is that beneficence toward the patient was the overriding ethical imperative of the nurse in question. The second is the relief on the part of the physician in knowing that his patient’s INR was normal. The bottom line is: “Why wait for urgent problems and crises before seeking guardianship for patients who known to be incompetent?”

Dr. Puerini is the Chief Medical Officer for the Oregon State Correctional Institution in Salem, Oregon. Dr. Rieger is the Corporate Medical Director for Correct Care Solutions in Nashville, Tennessee. Readers may contact the authors at mike.t.puerini@doc.state.or and drieger@correctcaresolutions.com.