Mr. Smith was an 80-year-old man admitted to the inpatient medicine service following a suicide attempt by ingestion of an unknown amount of hydrocodone-acetaminophen and alcohol. The patient was transported by ambulance, accompanied by his daughter. His daughter was also his appointed medical power of attorney and had a copy of the patient's advance directive, where he had indicated his wish not to be resuscitated (DNR) in case of a life-threatening emergency.Soon after his arrival to the hospital, a dramatic series of events unfolded. The emergency department treatment team learned the patient's suicide attempt was carried out as part of a suicide pact with his wife. She died by suicide. In addition, on arrival to the emergency department, the patient refused treatment with N-acetylcysteine (NAC) for management of acetaminophen (APAP) toxicity, continuing to express a wish to die. He voiced desire to end his life on his own terms, explaining his choice as a means to end suffering from chronic pain. He voiced feeling inadequate due to his own medical concerns, limiting his ability to care for his ailing wife. He stated he and his wife decided many years prior, through their engagement with the Hemlock Society, they would choose “when to die, when the time is right, and this seemed like the best time as we had a fulfilling life and did not wish to be a burden on anyone as we aged.”The treatment team in the emergency department was split. Some physicians determined the patient lacked decisional capacity to refuse treatment with NAC as this was a self-harm attempt. A few others felt the patient had capacity to refuse treatment as his concerns about poor quality of life were valid. But the treatment team's conundrum of timely and appropriate management of APAP toxicity (mitigate the risk of irreversible liver injury) against the patient's will, was further complicated by his daughter's (medical POA) refusal to allow NAC treatment. His daughter cited patient's advance care directive as a reason to “not pursue aggressive treatment that could prolong his life.”The treatment team was stuck. Mr. Smith's act of self-harm was of high lethality. APAP level six hours post-ingestion was 200 mcg/ml (normal: 10-20 mcg/ml). Besides mild emesis, he remained asymptomatic and in no acute distress. However, given the drug's pharmacokinetics, without timely treatment with NAC, he was at an acutely elevated risk of developing irreversible liver dysfunction (72 hours from ingestion), eventually resulting in coagulopathies, metabolic acidosis, encephalopathy, and ultimately death.Psychiatry was consulted regarding following issues: 1) Determining patient's capacity to refuse treatment with NAC; 2) Evaluate feasibility of treatment against patient's wishes if patient was deemed to lack decisional capacity; and 3) Advise on how to navigate a situation where surrogate decision maker was declining a lifesaving intervention, citing patient's advance directive of DNR as a guiding force for this decision.Relevant to case: On day 1 of psychiatry assessment, patient continued to express a wish to die, had not processed the loss of his spouse and was mildly encephalopathic from APAP overdose. It was deemed he lacked decisional capacity to refuse treatment with NAC, but the feasibility of treatment against will with intravenous NAC was a challenge as it would have required restraining him. The treatment team was finally able to explain to the surrogate decision maker that 1) the patient was not medically decompensated to the point of needing resuscitation. He was communicating, comfortable, and in no acute distress. 2) This was not a medical emergency, instead a medical urgency. 3) The consequences of failing to treat with NAC in a timely manner would result in a slow, painful death over weeks with evolving liver failure and sequelae 4) Should patient's APAP levels continue to trend upward despite treatment NAC and liver function is no longer salvageable, the treatment team would not pursue measures to prolong his life, per patient's request.The following day, he was lucid, denied history suggestive of a mood disorder, psychosis, or neurocognitive disorder. He was mourning the loss of his wife. He no longer wished to die, reflecting on his survival, purpose in life, and sought meaning in his grief. He planned to live with his daughter after discharge. The psychiatry team did not pursue psychiatric admission for the patient as he was determined to have decisional capacity to make own treatment choices.
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Aug 12, 2024
Shogo Taira + 3
Open Access