Ethics in Practice

On call, I am paged for a potential emergency case in the cath lab. A 90 year old woman with atrial fibrillation threw a clot to her brain. She presented several hours ago with a dense stroke; she couldn't speak, couldn't move her left side. The neurologist who saw her ordered tPA, a clot buster, but because of the extent of the stroke, wanted our neurointerventional radiologist to see her. The interventionalist thought he could guide a catheter into the blood vessels of the brain and pull the clot out. This would require general anesthesia, so I was called in.

When I examine the patient an hour later, her symptoms are markedly better. She has begun to talk and can lift her left arm and leg against gravity. Her examination is fascinating, the kind of thing that convinces medical students to go into neurology. She understands what we're saying to her, but has an expressive aphasia; she can't say complex sentences. When you ask her to tell us her name, she says she can't say it. But when you ask her, "Is it Sarah? Mary? Angela?" she'll answer correctly. If she doesn't get better from this, it will change her life. She lives independently; in fact, she has no other family members. Devastating strokes can take away someone's entire way of living. Although she was much better than when she presented, she still had real deficits.

The ethical dilemma arose. She didn't think she was having a stroke. Consequently, she didn't want to have the neuro interventional procedure. She consistently said she didn't want invasive procedures. But this was founded on a delusion of not having a stroke, which could have been caused by the stroke. It's a little confusing. In medical school, informed consent seems like such a straightforward thing. How could it be an ethically wrought subject? But at 2AM, with a stroking 90 year old patient, a procedure without risk that could return someone to independence, it's a real challenge.

On our investigation, there was no one else to make decisions for this patient. That, of course, would have been the best recourse. So I really probed the patient's competency to make this decision. Other than her disbelief that she needed the procedure, she seemed to understand what it involved and the risks. She adamantly didn't want it.

I also was not so sure that the benefits of this procedure outweighed the risks. She had already gotten significantly better with tPA, and a procedure like this can lead to further strokes and bleeding. The best trials for this procedure looked at the larger proximal vessels where tPA is less effective; her strokes seemed to be more distal. 

Ultimately, in talking to the patient, neurologist, and proceduralist, we decided to cancel the case. It is not ethically permissible to force a patient to undergo a procedure she does not want. The patient's lack of insight into her disease blurred the solidity of informed consent, but we felt that she understood enough to decline it. We admitted her to the hospital in hopes that with further anticoagulation and therapy, she will get better.