patient consent issues

[J.R.theR.N2b]

while surfing the web, i came upon a full discussion of the dax cowart case. he was severely burned in a gasoline explosion, suffering major burn injuries over most of his body, even his eyes. he asked a bystander who found him for a gun, begged EMS responders not to transport him, and ER staff not to treat him. he was in extensive pain and wished to refuse treatment he wanted to be allowed to die. staff determined he was not competent to make a decision of this magnitude while in such pain and treated him anyway. he describes procedures such as daily tankings in what he called a "hubbard tank", and after stretching bandages over his entire legs, wet them and then allowed to dry, after which they were pulled from his legs. this was excruciating and all he could do was scream. he was given minimum sedation, certainly not sufficient to stop his pain. all through his hospitalization he continued to beg to be allowed to refuse further treatment and was denied, even after a psychiatric evaluation was done in which he was found to be competent. i realize that this was a 1973 case and that trenendous inroads have been made in the treatment of pain, but it reminded me of a question i have long thought about. if dax cowart were admitted to a hospital today in the very exact scenario he did then, what might be the outcome? no one could argue his competency to make major medical decisions when he presented to the ER. if a patient in this situation with his only respite from agonizing pain when he could fall asleep, and sedation could not make it tolerable what might happen to him? would he ever have been allowed to refuse further treatment? i hope that sedation and pain relief have come far enough so this situation could no longer occur. for more information-----------google dax cowart. thank you very much.

[MedSurgeMess]

I think I'm glad that I don't work in an ER. I would be so torn--to honor the patient and his wishes, or to try to preserve life. This is where I would call the facility ethics committee. I can relate to where this case is coming from, I don't think I'd want to live either......

[justiceforjoy]

I think we induce comas in burn victims like in this case, now.

Absolutely, pain can make people want to die; we have to first control the pain before any mental examinations can be done.

[pricklypear]

When I worked ICU, we had a patient who basically had a dead body but a living brain who constantly asked (he mouthed words since he was vented) to be allowed to die. This was a previously very robust and healthy man who suffered a sudden, traumatic injury. He was deemed "incompetent" by his "saviors" and his agony was dragged out for several months. It was horrible to have to care for him- his suffering was obvious, but there was nothing you could do. Several nurses refused to be assigned to him for ethical reasons.

The ethics committee was involved, but sided with everyone except the patient. I think it paid more to keep him alive - he had good insurance.

This will continue to happen until people make their wishes known BEFORE something happens, and families stand up and fight for what they know their loved-one wants.

I wish some of these doctors could live for just 24 hours with the agony that some people are forced to endure. Outcomes might be different. It's just pretty scary.

[pricklypear]

Absolutely, pain can make people want to die; we have to first control the pain before any mental examinations can be done.

The downside is, that once narcotics are introduced, "incompetency" can be claimed.

[Valerie Salva, BSN, RN]

I think his pain could have been controlled. I don't think that a person should be allowed to make the decision to die immediately after a severe traumatic injury occurs- they are not in a rational frame of mind right at the time of the event.

Agressive pain mgmt should be a very high priority, along with initial emergency tx. After the pain is controlled and the pt has been somewhat stabilized, then I think a competent person should be allowed to refuse curative tx, and choose palliative care only- and be allowed to die.

A person with severe burns would likely die of dehydration, hypothermia, organ failure and infection pretty quickly.

I have participated in the care of terminal pts who were treated with palliative sedation, and allowed to die. In the few cases I've seen, I think it was the right choice in each situation.

[pricklypear]

I guess I'm just so disheartened because I've seen such disregard for individual wishes. I've seen such disregard for the need for pain relief. Or, I should say, patients with extensive burns/trauma just might need very large amounts of pain medication instead of the "usual dosage." I've heard too many times, "That is a larger than average amount of medication, I'm not comfortable ordering that."

BTW, the video of this man speaking at a university was VERY moving.

http://www.uwtv.org/programs/displayevent.aspx?rID=3619&fID=567

[justiceforjoy]

I guess I'm just so disheartened because I've seen such disregard for individual wishes. I've seen such disregard for the need for pain relief. Or, I should say, patients with extensive burns/trauma just might need very large amounts of pain medication instead of the "usual dosage." I've heard too many times, "That is a larger than average amount of medication, I'm not comfortable ordering that."

BTW, the video of this man speaking at a university was VERY moving.

http://www.uwtv.org/programs/displayevent.aspx?rID=3619&fID=567

Thank you for sharing that video.

[BrnEyedGirl, BSN, MSN, RN, APRN]

There are too many lawyers,....if the victim is allowed to die he/she will have many family members with lawyers who will sue. As an ER nurse this is one of the more frustrating aspects of my job. The 93yr old with a DNR, the long lost great niece who hasn't seen her aunt in 5yrs shows up and cries to do anything to save her "favorite aunt". Unfortunately she wins as she will still be alive to hire an attorney. Very sad and selfish.