Ethics In Our Practice: Doing Nothing by Jim Ducharme MD CM FRCP
Friday, February 26, 2010 
Jim Ducharme MD CM FRCPI went to work a couple of weeks ago and had a remarkable patient encounter. I went to see a 95 year old lady who was complaining of chest pain and dyspnea. I introduced myself; her first statement to me was: “why is everyone making my dying so complicated?”
This was a wonderful woman, very alert, with a twinkle in her eye. She had come in 2 weeks earlier with chest pain and a STEMI. Without asking her approval, she was transferred to the cardiac cath centre and had a stent placed – “they just told me what was going to happen.” Here she was again, with crackles in her bases and signs of an acute sub-endocardial MI on her ECG.
So what did I do? I sat down and had a great chat with this woman; she talked about her life and how she was ready to die. She said she had done everything she had wanted to do. Her son arrived, and talked to me away from his mother. He was crying, saying he was finding it very difficult to accede to her wishes because she was ‘so with it’. Amazing isn’t it? We resuscitate demented patients who are septic because they cannot express their opinions and do not have advanced directives. In this case 2 weeks earlier we performed invasive care on someone who wanted none. Why can’t we let go?
Not actual patient
I had another talk with the woman, and with smiles on both of our faces we said goodbye, she returning to her nursing home, me caring for other patients. She had received what we both perceived as her best possible care – a listening ear and an empathetic heart.
I remember being told once that there are no ethical decisions in the ED: you treat them and someone else takes the time to consider ethics. I taught at a bioethics practicum for a few years: the learners were always uncomfortable wrestling with the ED scenarios I presented, often saying they could not decide as they did not have enough information. I believe such a statement is the same as saying you will not buy a cell phone because it will instantly be out of date – at some point you just have to decide.
We are getting better in the ED at making ethical decisions, although we still seemed confused at times between moral decisions and ethical ones. Doing nothing is often the best decision, yet it seems very hard to do: writing prescriptions for a medication that cannot help because ‘we have to give them something’; letting someone die or recognizing further care is futile. I would suggest that doing nothing is actually an active choice and in many cases the best ethical one.
Certainly my patient and I felt good about our decision…
Reader Comments (4)
Thanks for this post. About one week ago we resuscitated a older lady to came in to the ED who was in multisystem organ failure, who went into cardiac arrest while she was there. We got a hold of her daughter who of course wanted everything done. The patient didn't have a voice, so we did everything we could. We eventually got a rhythm back on her and shipped a shock trauma ICU only for her to be pronounce brain dead the next day. This situation really made me wish I had known what the patient might have wanted so we didn't have to put her through all of that.
Thanks
Melissa T, RN
IMC and Riverton Emergency departments
Thanks for this post. See my similar sentiments in my Feb 15th post - rules for respecting the elderly. My philisophy is not to do nothing, but to do something caring instead of something medical. Physical comfort and dignity should be our priorities.
Great post. This is why I'll read anything that has Jim Ducharme's name at the top.
I hear echoes of the Fat Man's 13th law of the House of God...
http://www.em-blog.com/blog/2011/3/14/ricks-picks-no-8-ed-translators.html