Whether No Means No
Silverman, Lewis M.
Smith, David A.
Hastings Center Report. 1992 May-Jun; 22(3): 26-27.
Dr. D is an emergency physician in a large urban hospital. One relatively quiet evening Mr. R, a thirty-two-year-old male, presents to the emergency department complaining of shortness of breath. The problem, as it develops, is a depressingly familiar one to Dr. D. Mr. R, known to be HIV positive, turns out to be having his first episode of pneumocystis pneumonia, an often fatal disease of AIDS patients. The episode, fortunately, appears at present to be a relatively mild one; his blood test shows his lung function is only moderately impaired....As they grapple with the news that Mr. R has now changed from being a patient with HIV to one with AIDS, Mr. R and Mr. U produce a living will and durable health care proxy form designating Mr. U as responsible for decisionmaking if Mr. R becomes incompetent. The living will forbids cardiopulmonary resuscitation and prohibits "under any circumstances" endotracheal intubation and respirator ventilation, along with numerous other measures....Mr. R is in anaphylactic shock. Quickly ordering the four appropriate medications, Dr. D opens his mouth to ask for an endotracheal tube and respirator -- and realizes he has a problem. Mr. R will die as the airway closes up if patency is not immediately ensured by placement of a tube. Indeed, in a case like this, placement often requires cutting the patient's throat to maintain the rapidly narrowing airway. Seconds, quite literally, count. The good news is that this is a time-limited condition. With immediate aggressive action, only a few hours or days of ventilator support should be necessary and there should be absolutely no long-term sequelae. Of course, it is possible that Mr. R's pneumonia will acutely worsen. He might then be unable to be weaned off the respirator. An emergency physician with no experience in the long-term management of either pneumocystis pneumonia or anaphylaxis, he is unsure of the chances of that. What should Dr. D do?
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