Medical Ethics Question

By John Ballard

Last week's New England Journal of Medicine has a first-person account of a physician faced with a legal-ethical-practical puzzle when during a transcontinental flight a nearby passenger has a medical emergency. 

What would you do, if anything, under the circumstances if you were the doctor? A passenger? A flight attendant?

Our plane was flying from the East Coast to the West carrying 167 passengers, including my wife, a hospitalist and internist, and me, a neurologist and clinical ethicist. About midflight, a woman in the row behind us reached frantically for the baggage bin over our heads. I offered to help. She was trying to get her husband's oxygen tank.

I turned and saw that he looked to be about 70 years old. His eyes were closed, and his right hand was clutching his chest as he grimaced in pain. Immediately, his grimace faded and his right arm dropped. Leaning over my seat, I caught his hand and felt for a pulse while my wife checked for the radial pulse in his left arm. There was none. Two flight attendants approached. �I am a physician,� I said. �Let's get him down to the floor.�

We lifted him into the aisle. I shined a pocket flashlight on the dimly lit scene. He had stopped breathing; his pulse was absent. We tore open his shirt to reveal a well-healed thoracotomy scar.

A flight attendant brought an automated external defibrillator (AED), an Ambu bag, and other equipment. Three other passengers � an oncologist, an anesthesiologist, and a surgeon � joined us. My wife ran the code, I provided chest compressions, the anesthesiologist bagged the patient, the oncologist managed the equipment, and the surgeon attempted venous cannulation and then intracardiac injection of epinephrine. We confirmed that there was a femoral pulse only with chest compressions.

We followed the protocol suggested by the AED. The device did not discharge, since its automatic rhythm-detection program had found no rhythm that might be treated with defibrillation. The monitor eventually showed a wide complex bradycardia with which we could not associate a palpable pulse.

Our resuscitative efforts were taking place in full view of the passengers and the man's wife, who stood beside us. Five previously rambunctious children were now silent.

After 25 minutes of basic cardiac life support, there was still only pulseless electrical activity. The five physicians agreed that it was time to stop the code and declare the patient dead. But the flight attendant explained that if we stopped CPR, the airline's protocol would require the cabin crew to continue it in our stead. �This is futile,� muttered the surgeon, and without discussion, he returned to his seat, leaving four of us facing a dilemma: If we turned the resuscitative efforts over to the crew, who would look after the passengers? But if we continued CPR, we would be treating a patient who had clearly been �overmastered� by his disease.

The proper practice of medicine does not include treating irreversible disease when patients are overcome by illness. This principle holds true even when family members request futile interventions or when physicians are following a well-meaning protocol. To prolong CPR under the circumstances in which we found ourselves would be to subvert medicine's goal from the good of the patient to the benefit of the community. Given this understanding, we could not consider our actions to be within the scope of the practice of medicine; rather, as we continued administering CPR, we were acting less as physicians than as skilled passengers assisting a flight crew.

The pilot announced that he was diverting the plane to a small airport. The crew calmed the passengers, addressed their other needs, and attended to landing preparations. As we descended steeply, the pilot ordered everyone to be seated. The anesthesiologist and oncologist complied. We were down to two physicians administering CPR. A flight attendant took over the use of the Ambu bag and required coaching on technique. I was instructed to hold onto my wife as she continued chest compressions, both of us half-strapped into stretched safety belts to allow us to continue CPR during the landing.

We landed with a light bump, then braked and taxied along the 6500-ft runway to a stop. The resuscitative efforts had continued for some 35 to 40 minutes. Firefighters and paramedics arrived and carried the patient to the door and down a fire-truck ladder. He died that day, according to news reports we later found online. As it turned out, he had also been a physician.

We had knowingly delivered medically ineffective CPR. But we did so because of practical concerns arising from the demands of the airline's protocol. CPR was going to go forward whatever we decided, and we chose to continue it ourselves so that the four flight attendants could attend to their duties during an emergency landing.

On solid ground, I believe that medical policy and protocols should preclude such dilemmas. The responsibility for deciding to stop CPR should rest with a physician who is focused solely on the good of the patient. CPR should be deemed ineffective when it cannot be expected to meaningfully alter the natural course of the disease; it should be deemed futile when it no longer serves the patient. We should ensure that our medical policies and protocols exclude considerations such as mitigation of liability or the exclusive interests of third parties from playing a role in resuscitative decisions. Such policies will help support the efforts of physicians to act always for the good of the patient and within the bounds enunciated in the Hippocratic Corpus.

I toss this out to illustrate how byzantine medical issues can become. To me what's wrong with this picture is that the last option on everyone's list is common sense. If in the professional opinion of five doctors the man is dead, why not carry the body to the destination and have police on hand to take delivery? But I tend to be simple-minded.

One of my children is a former flight attendant with seven years' experience. She pointed out that when someone dies in the air it is almost impossible to determine exactly where they died (over what state or country) -- which can have legal ramifications when settling any estate -- which in turn is determined by the exact time of death. Forensic questions are important, but it seems to me that for legal reasons in this case the answers are more formal than accurate.

If you want to see a sterling example of an intelligent comments thread, take a look at what comes up in the New England Journal of Medicine. Quite a refreshing change from the sniping and quarreling we see in the backwaters of the political world.
Among eighty comments now listed is one marked "Elma Lou Roda | Physician | November 18, 2010 Just Want to Say Thanks" a warm and personal expression of grattitude from the widow of the deceased. 

?Thanks to Accidental Blogger for the link.