Tuesday, May 20, 2008

Where's the 'first do no harm' line again?

Scalpel wrote a post earlier this month about a cutters' (ie, self-injury) forum, and in the course of the commenting someone mentioned a young man who cut himself so severely and so often that his hemoglobin was chronically in the toilet--like in the low single digits (normal is around 13). Eventually the doctors who had been giving him blood transfusions cut him off--no pun intended, because man, joking about this would really mean I'm going to hell, like today, instead of at some vague and ill-defined point in the future--and lo, he 'rationed' his cutting so that he wasn't sucking down packed cells like Vlad the Impaler at happy hour. In all, I think this could be called a positive outcome for all concerned, assuming the guy learned to 'make do' with less cutting and maybe--just maybe--picked up some alternative coping skills.
But here's my question: I could just as easily see this going another way...what happens to the treatment plan when Joe Kidd shows up in the ER with a hemoglobin of 5? Is it justifiable to withhold treatment? Do you catch and release, bumping him up into the double digits and waiting for him to come back (a less extreme example might be someone whose wounds routinely need sutures)? Should he be given another transfusion, but this time also be forced to enjoy a 72 hour vacay on a mental health unit? To those who balk at involuntary commitments, what about making receipt of the blood contingent on his signing into the psych ward? Does dressing it up in different clothes change the ethical implications?
What about providing potassium for a purging anorexic or bulimic who presents with a 2.9? Of course you do it the first time, and the second, and the third. But what about the fifteenth? Does the answer change if she's actively engaged in outpatient therapy, or if she's been in and out of treatment centers? What's the point at which you say (and ostensibly this would be a primary care physician, not someone down at the ER), "Hey, why don't you take these 40 mEq of potassium every day until I say stop?" Or is that, as some physicians argue (boneheadedly, in my opinion, and as though attempting to prove to all and sundry just how little they understand about eating disorders) merely giving patients "permission" to purge?
In short, when does "This is what you SHOULD be doing, dammit!" turn into "OK, if you're going to do that anyway, here are ways to reduce the risk and here's a safety net"?
And just a little devil's advocacy here (I swear I've never been able to look at Al Pacino the same way since I saw that movie--hands up everyone who got the reference), it is beyond standard practice for patients to come in, say "I kind of tried to walk more and watch what I ate, but not really" and have the doc shrug and write out scripts for Zocor, Glucophage and Benicar. So who gets enabled when, and what makes the difference? Is it simply that some behaviors (cutting, eating disorders, chronic suicidality) are so dramatic and hold such stigma that extreme measures 'become' justified, even at the expense of respecting the person's autonomy? Or is that precisely a caregiver's role at times: to make treatment decisions a patient isn't able or qualified to make, and to act in her best interest (even if it means denying her wishes) when she can't?

No comments: