By Dr. Muggenthaler – specialist in anaesthesia and palliative medicine
Patient: female, born in 1915
Diagnoses: status post stroke, dependent on care for seven years, status post total hip replacement, cachexia
Social situation: The patient was cared for at home by her son and his partner; medical care was provided by the family doctor.
One evening in October 2002, the emergency physician and the Bavarian Red Cross ambulance crew were alerted through the rescue control centre with the report “Cardia 4”, an unconscious person, in a small town. After a journey of 17 minutes, the emergency physician and the driver of the emergency doctor vehicle reached the scene; the ambulance crew was already there. In a small room the rescue service found an 87-year-old woman lying in a nursing bed in a cachectic condition. At first glance she had severe contractures. Her son and his partner were also in the room.
The son reported, hectically and in a confused way, repeatedly interrupted by short arguments with his partner, that his mother was apparently not well and that she had been like this since the last visit to the urologist. Further third-party history showed that the patient had been dependent on care for seven years and had vomited “dark” material. Clinical examination showed pronounced cachexia, clear volume depletion, contractures of all major joints and marked hypotension. Cardiac action was arrhythmic; rales could be heard over both lungs. The patient was barely responsive. To the emergency physician, who had palliative medical training, the overall picture was that of a person in the dying process.
In a calm and detailed conversation, in the presence of the rescue service crew, the emergency physician told the son and his partner that his mother was in the dying process and that the point of no return had been reached. Hospital admission was no longer indicated in this condition. Instead, his mother could remain at home and die in familiar surroundings. Symptom control could be started by the emergency physician and continued by the family doctor if necessary. The son and his partner agreed to this approach. From the detailed conversation with the son, who had cared for his mother for years, the emergency physician concluded that this approach also corresponded to the presumed will of the patient. Because of the pronounced volume depletion, hypotension and the feeling that something should be done, an infusion was nevertheless placed and 500 ml of electrolyte solution administered. The patient died at home that same night.
A few days later the emergency physician received notice that the public prosecutor’s office was opening investigations on suspicion of negligent homicide. The patient’s son had filed a complaint alleging that the patient had not been adequately treated and that hospital admission had been wrongfully omitted. He based this on the fact that his mother had died almost two hours after the emergency physician’s intervention. The autopsy at the university department of forensic medicine showed a clearly reduced general and nutritional condition, severe coronary heart disease with three-vessel disease and a thrombus in the right coronary artery directly at its origin, probably causing acute heart failure, aspiration pneumonia, cerebral and pulmonary oedema, and bleeding in the right basal ganglia of the cerebrum.
The forensic medical report concluded that it could not be established, with the certainty required in criminal law, that the emergency physician could be accused of medical misconduct that was causally responsible for the patient’s death. Even in 2002, no duty to admit a dying patient to hospital could be derived from the law then in force. The emergency physician on duty also saw it at that time as the right of every person to be allowed to die with dignity in their home environment. Accordingly, the Federal Court of Justice had already correctly stated, regarding medical treatment in the border area between life and death, that medical professional ethics do not stand isolated alongside the law but constantly enter into the legal relationship between doctor and patient. More than in other social relationships, the ethical and the legal flow together in the medical sphere. Therefore, in decision-making the physician may not disregard the social-ethical interests of the legal community in which doctor and patient live.
Discussion
It corresponds to the physician’s self-understanding that, for an unconscious or otherwise incapable patient, the help to be provided is directed toward preserving life as long as there is a prospect of improvement in a person close to death or seriously injured. On the other hand, the physician may consider that there is no legal obligation to preserve an extinguishing life at any price. Life-prolonging measures are not indispensable simply because they are technically possible. In view of medical technology that exceeds previous limits, it is not the efficiency of the apparatus but the individual decision oriented toward respect for life and human dignity that defines the limit of the physician’s duty to treat. In a later decision, the Federal Court of Justice further stated that life-prolonging measures are not required when, according to medical conviction, the patient’s underlying disease is irreversible, has taken a fatal course and death will occur within a short time. The proceedings were finally discontinued four months after the incident.
Conclusion
The implementation of specialised outpatient palliative care (SAPV) and emergency pastoral care now makes it possible to avoid, as far as possible, situations such as the one described in this case report. SAPV also attends intensively to the psychosocial needs of relatives, and the 24-hour on-call service gives patients and relatives a constant point of contact for their concerns. The referral of an emergency chaplain through the integrated control centres rounds off the psychosocial support available to those affected.
