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Inside The Ethics Committee with Joan Bakewell

Thursday 19 July 2012, 08:00

Beth Eastwood Beth Eastwood

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Editor's note: Inside The Ethics Committee returns this week with the subject of Restraining Patients In Intensive Care. You can listen again to the programme or download the series for free. PM

Joan Bakewell

Hospital is where we go to get well and we expect to give informed consent for our treatment. But what happens when a patient actively resists the treatment that will save them?

In BBC Radio 4's Inside the Ethics Committee, Joan Bakewell is joined by a panel of experts who wrestle with this ethically challenging question.

They look at the case of 29 year old Monty. Earlier this year he started having trouble breathing, became more withdrawn and was eventually rushed to hospital and transferred straight to intensive care.

Monty is diagnosed with double pneumonia and, unable to breathe sufficiently on his own, he is placed on a ventilator and sedated so he can tolerate a breathing tube in his throat. The ventilator delivers high levels of oxygen into his lungs and does his breathing for him. After several days on antibiotics, his lungs start to recover.

Staying on a ventilator longer than Monty needs is risky, so the team are keen to get him off the ventilator and breathing for himself, as soon as possible. To do this, they stop the sedation, and over several hours Monty gradually wakes up. The plan is to remove Monty's breathing tube and then place a mask over his face to support his breathing until he is strong enough to breathe unaided.

But things don't go according to plan. Monty is autistic, and as soon as the mask is placed over his face, he bats it off. The nurses put it back on, but he gets up from the bed forcing the mask away. The nurses persist, but Monty struggles and lashes out at them. Exhausted and breathless, he starts turning blue. Fearing for Monty's life, the team re-sedate him and put him back on the ventilator. Desperate for a solution, the team try the mask again, but again he resists while the nurses and carers try desperately to stop him.

As his life hangs in the balance,

  • What lengths can the medical team go to to get Monty to accept the life-saving treatment he is struggling against?
  • Is it ethical to tie Monty to the bed?
  • Does Monty have the right to refuse?

Joan Bakewell is joined on the panel by Dr Gilbert Park, Consultant in Intensive Care at North Middlesex University Hospital, Deborah Bowman, Professor of Ethics and Law at St George's Hospital in London, Catherine Plowright, a Nurse Consultant at Medway Hospital and a Professional Advisor at the British Association of Critical Care Nurses and Professor Tony Holland, Chair in Learning Disabilities in the Department of Psychiatry at the University of Cambridge.

Beth Eastwood is producer of Inside The Ethics Comittee

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    Comment number 1.

    I found this very depressing and distressing. People with learning difficulties need much more assistance in hospitals. My daughter with learning difficulties will need a heart operation next year and I'm dreading it. I need to explain what will happen to her in lots of different ways eg symbols, words, photos and videos. I hope the hospital will be able to help with this, well in advance, as she does not cope well with tubes, attachments, blood etc

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    Comment number 2.

    What a sad start and provocative start to a new series.
    Why did the Ethics Committee not spot at the outset that the medical profession was failing in its duty to treat Monty with the care and respect it would have accorded someone who wasn’t “autistic”? If Monty’s impairment had been blindness, his treatment regime would have been adapted to suit his needs. Instead he almost died as a result of the treatment. Would a blind person have been judged as “lacking capacity” if (s)he continually bumped into things if the treatment required running around in a strange place?
    The clinicians only saw double pneumonia and embarked on their treatment regardless. The hospital was worried about the risk Monty posed to staff; Monty was moved to a side room “so we could control him” with the added bonus that it would remove “the anxiety of what others might think”. Even his restraints were delayed for 24 hours whilst someone checked for the correct catalogue number.
    Monty’s response the “assaults” of strange people in a strange place should have been assessed and predicted. Why, after the first failed attempt, did no one consider whether treatment at home in with his loved ones in familiar surroundings was not more appropriate?
    Tony Holland admitted as much at the end of the programme when he acknowledged that restraint should only be “in the context of all other things that could be done to help Monty understand... it should be for the briefest period of time...you should think of how you get Monty out of bed and back home as quickly as possible so that he is back to a familiar environment”.
    Exactly, so the first question is why that didn’t happen.
    Secondly, why is so little resource, knowledge and respect accorded to people who have “autism” or a “learning disability”? Compare this with the resource, knowledge and respect focussed on people whose treatment is a result of natural causes such as infertility or avoidable issues such as smoking and lack of exercise. This vital human rights issue was completely missed.

  • rate this
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    Comment number 3.

    Good God! This so called Ethical 'hypothetical scenario' programme involving a 29 year old critically ill autistic male called Monty utterly infuriated me: it was like a painful hour-long wallow in a pool of vascillating jellyfish!

    What was the criteria? Should he live or should he die, and did anyone care? Yes, someone did, or they wouldn't have brought him in, and were also able to explain that he was autistic, was over the age of consent but not necessarily able to understand what was in his best interest to ensure his future life. (Did he want a future life? Well, lots of us don't, but you ,the bloody Medical Profession, insist that we all do have to have one, compus mentus half-dead or not! So why make a 'headline' exception for someone who is just autistic?)

    If his 'knowing' Carer/parent has insisted that he would want to live, if fully compus mentus, and its not unfeasible to medically render him so, then I think the Medical profession should have the balls to do so, and if restraint needs to be incurred, then to restrain him to heath. Cruel to be kind... Hippocratic Oath inviolate... Yes!

    To anyone else of fully 'sane' mind? No. If they want to die, then let them. And to Carers? Sometimes, knowing the person, you show a far greater love in letting them go, than in fruitlessly hanging onto them...

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    Comment number 4.

    If Monty isn't capable of understanding that the treatment is in his best interests due to the degree of Autism he has, then I think he should have been restrained if there really is no other way to solve the problem. I didn't get the impression that the medical staff were being insensitive to his condition. I mean, you don't let a 4 year put their hands on a burner, and if they have to get a shot, they get the shot, end of discussion. Surely the staff would have shown insensitivity to his plight if they had NOT attempted to put the mask on him the second time? If on the other hand Monty was capable of understanding what role the mask was to play in his recovery, and if he chose to risk not using it to aid his breathing, then that's his lookout. One's life is one's own...more importantly so in this cruel age of austerity and cut backs. We're not here to assuage some politician's feelings of guilt, if indeed they have any...

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    Comment number 5.

    I was interested in this debate on restraint, But I don't understand why the changing of the atmosphere was not discuss for Monty. 'the mask' was hardly ever questioned as the delivery method of oxygen, could a inflatable oxygen tent of an appropriate size be used, Michael Jackson had one every night! I understand oxygen is a stable element at 21% in normal atmospheric conditions but in high concentrations is very flammable, after the ventilation a 40% oxygen concentration required to aid recover is this a reasonable safe level? Could the 40% concentration be maintain in a oxygen tent and can medical staff operate in these conditions? Modifications would be need as electrical equipment would have to be kept out side and its services piped in. surely the initial cost must be counteracted by the repeated sedation, repeated ventilation, secondary infections, tracheotomy and the large amount of work hours and consultation require and not forgetting stress for Monty. Is a oxygen tent a viable option?

    As for myself I understand the need for physically restrain in the correct situation after good consultation. Visibility should be its strongest safeguard.

 

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