Life as an Extreme Sport

to intubate or not to intubate, that is the big ethical question

We’re in the middle of an impressive snowfall, so I’ve decided to curl up on my couch and watch TV. Currently, an older episode of House is playing, and as you well know, I love the ethical spin the show brings. To catch you up on what’s happening, House doesn’t believe a patient has ALS. Patient thinks he has ALS and has signed a DNR while he can’t. House’s team decided to try a medication on top of what the patient was already receiving, to rule out another possibility for paralysis. The patient reacted badly to the medication, and went into respiratory distress. House’s team refused to intubate, citing the DNR, so House intubated and bagged the patient, then placed him on a vent.

House: Everyone knows what’s wrong with me. What’s wrong with him is much more interesting.
Foreman: You tubed him and he didn’t want to be tubed! He has the legal papers saying just that!
House: To intubate or not to intubate, that is the big ethical question. Actually, I was hoping we could avoid it and maybe just practice some medicine.
Foreman: There’s no question. It’s the patient’s decision!
House: If the patient is competent to make it. If his thyroid numbers aren’t making him sad.
Foreman: Oh my god, you don’t believe that.
Cameron: His thyroid levels were a little-
Foreman: It’s nothing. Do NOT defend him.
House: Why do you think he signed that DNR?
Foreman: Wha – I didn’t talk him into it!
House: No, he signed a DNR because he didn’t want a slow, painful death from the ALS. What was happening to him had nothing to do with the ALS.
Foreman: Right! Exactly! It is the IViG! You screwed up! You’re not going to let him die because you screwed up!
House: Technically, your case. You screwed up. Is that what this is about? Looking bad in front of your old boss.
Foreman: You assaulted that man.
House: Fine. I’ll never do it again.
Foreman: Yes you will.
House: All the more reason this debate is pointless.

So, who’s right here? Is House right – do you intubate because the patient was not dying because of the ALS? Or is Foreman right, and House assaulted the patient?

Now, in many treatment facilities, this entire scenario is moot because the DNR (which, as House notes earlier in the episode, stands for do no resuscitate, not do not treat) is specific enough that you can actually decide things like whether or not you want treatment for medical issues not related to your primary diagnosis. You can specify out how far you want treatment, at what point it should stop, even if you want only comfort care. Of course, the key here is “many” – I’ve seen DNR forms that simply specify no treatment and that the patient should be allowed to die from whatever disease or illness they have; this is when the scenario that played out in the episode of House comes in to play. At what point is it assault, when is it treatment, when is it counteracting side effects of treatment, and when do you just stop?

So I’m curious – given the scenario outlined above, where a patient has a non-descript DNR and a side effect from a treatment not treating the primary condition, what do you do?