In considering the motivations and conduct of an ER doctor, should paternalism be such a dirty word?

Consider the following example, in which the principles of a physician's duty for beneficence and a patient's right to autonomy come into conflict. Shades of grey predominate here.

An 80-year-old woman with a history of multiple medical problems, eccentricity, and perhaps early signs of dementia who lives alone is brought in by paramedics after neighbors call the police to perform a well-being check since they hadn't seen or heard from the woman in five days. They usually see or hear from her at least every other day. She wasn't answering her door, the mail and papers were piling up, and she wasn't answering her telephone.

The ER doctor examines her: The patient is somewhat irascible but oriented and seeming to follow the conversation. Both of her legs are swollen to just above the knee, red, and warm to the touch, but the left leg is much, much worse than the right. It is taut and sensitive to touch. Red streaks can be seen extending up to her groin from around the knee. The small toe on her left foot is turning black. She has a low-grade fever. She does not allow the doctor to examine the lymph nodes in her groin.

To the ER doctor, it is clear what must be done medically for this patient with a severe case of cellulitis. Though the patient doesn't have gangrene at this point, her risk to develop it is moderately high. And gangrene, of course would make the loss of limb, and possibly the loss of life, imminent so that the patient could then be taken to the operating room on the basis of the situation becoming a medical emergency.

The ER doctor, however, thought she could forestall the possible complication of gangrene if the patient would agree to have her blood drawn, blood cultures sent, x-rays of both feet and lower legs done to investigate for possible bone infection, IV antibiotics started, and consultation from a surgeon, who would see if an incision and drainage of the infection would be of benefit. The ER doctor saw the case as a severe but absolutely treatable infection.

The following questions could be posed to the ER doctor:

Was the patient at risk of losing her left leg imminently?  "Not really. She'll probably be okay for a day or two, but then . . ."

Was the patient at risk of dying imminently?  "No. Mentation and vital signs are actually okay. Sepsis would be the most dangerous thing and she's not there right now."

So what's going to happen if her leg infection goes untreated? What are the chances she is at risk to lose her leg or her life?  "I'd say the chances of her eventually requiring a life-saving amputation are high. Should we wait for that? Should we wait for her to get sepsis, to become delirious with a high fever, when her blood pressure would be bottoming out and she would be a much more dangerous candidate for surgery if that was necessary?"

So how does the ER doctor communicate her concern to the patient?

"How are you doing, Ms. Smith," asks Dr. Jones when returning to the exam room to discuss the situation.

"I really want to get out of here," says Ms. Smith. "There's no reason for me to be here."

"Actually, you are very sick. How much does your leg hurt?"

"No, it doesn't hurt in the least."

"I'm surprised because from my exam, it looks like you have a very serious infection of the legs called cellulitis, your left worse than your right."

"There's nothing wrong with my legs."

"But you were found down on the floor of your apartment. When the paramedics came, you weren't able to get up. They had to lift you on to the gurney."

(Silence from Ms. Smith.)

"There are a few things I recommend we do," says Dr. Jones.

(Still silence.)

"First of all, since you can't walk on your own and you're sick, I want to admit you to the hospital."

"You have no right. I didn't do anything to you. Why are you taking away my rights? I live a simple life. I like my independence, living by myself."

Ignoring the patient's protestations for the moment, Dr. Jones continues, "Plus, Ms. Smith, I'd like to draw your blood, start an intravenous line for antibiotics. You might even need surgery to relieve the pressure on your legs.  This infection is very severe, but I think we can overcome it if we get started now. You made it to the hospital just in time. Another day or two and you'd be at risk to die. If we don't treat it aggressively now, then there is a very high risk this infection can spread to the rest of your body and kill you."

"NO!" screams Ms. Smith. "I'll have none of it! I'm going home. Call my neighbor Phoebe, she'll come and get me, take me home."

Frustrated but diplomatic, Dr. Jones says calmly, "I hear what you're saying, Ms. Smith. You'd like to go home. You don't want us to do anything medically for you at this time. I'll come back in a little bit to talk more. This is a very serious infection and the treatment is straightforward and likely to work. I'd like you to think about it some more."

"Okay, doctor," says Ms. Smith, seemingly tired, the interaction stealing some of her energy.

But Dr. Jones knows how these things usually go. Ms. Smith will likely continue to refuse these potentially limb- and life-saving interventions.

And if that's the case, then Dr. Jones will have to obtain consultation from a psychiatrist to assess Ms. Smith's capacity, a clinical parameter, to make decisions regarding her medical care. And then she could apply to the court for a medical probate hearing to determine whether the patient has competency, a legal term, to make decisions regarding her medical care.

Unless, of course, what is now a medically urgent situation becomes a true emergency and then the doctor can proceed without the consent of the patient.

(To be continued)

Copyright Paul R. Linde, M.D.