Assignment task:
(To Implant or Not Implant? That is the Question).
You have recently matched with a residency program at a nearby hospital known for its trauma center. Your name is Dr. Goodfaith, for a good reason. You are a hopeful new doctor who wants to make a positive difference in your patients' lives. In medical school, you took a particular interest in medical ethics, especially pertaining to patient's rights and beginning- and end-of-life care.
Your new patient, 82-year-old, Russian born, Mr. Blue, has been admitted to the hospital for what appeared to be a low-lethality suicide attempt. Toxicology reports suggested that Mr. Blue had taken a handful of sleeping pills, which he claimed was accidental. He was brought in by his nephew, with whom he has a very contentious relationship. During this time, Mr. Blue was also experiencing episodes of bradycardia, which is defined by a very slow heart rate of under 60 beats per minute in adults. He received a temporary external pacemaker, which is only a stopgap used in emergency settings. You want to implant a permanent pacemaker to correct the life-threatening bradycardia, but Mr. Blue is adamantly refusing. He says that his "soul hurts" and that he doesn't wish to live much longer.
Because of the attempted suicide and the refusal of a life-saving treatment, the director of the ED has requested a psychiatric evaluation, and Mr. Blue's nephew agrees. Based on clinical assessments, observations, as well as written testimony by the nephew, Mr. Blue is diagnosed with type 1 bipolar disorder, treatment-resistant depression, and alcohol-use disorder. At this point, Mr. Blue's medical decision-making capacity is in question, and it is determined that you will pursue an "emergency commitment" which will require judicial approval. You now must navigate the complex process of determining mental competency.
In the meantime, you have to make a recommendation about the internal pacemaker, which is necessary to correct the bradycardia. You consult the attending physician, who evaluates the situation at large. She suggests that you administer ketamine to Mr. Blue, to address his acute depression, in hopes to improve his overall mood and motivate him to comply. Mr. Blue agrees to the ketamine treatment and responds favorably, as his mood improves significantly, and he no longer seems to be depressed. Much to your surprise, Mr. Blue soon reverses course regarding the pacemaker and opts to have the implant surgery. There is a catch. While he has agreed to the procedure, he is attributing this reversal to pressure applied by the medical team, which makes the victory of his decision bittersweet. You and the medical team now have an important decision to make.
Q1. What are the important facts in this case?
Q2. Should Dr. Goodfaith pursue the implantation of the pacemaker, even though Mr. Blue is claiming that his compliance is because of pressure from the medical team?
Q3. Are there any potential legal issues that could arise as a result of either proceeding or not proceeding with the pacemaker implant?
Q4. Are there cultural competency issues at play here? Meaning, Could Mr. Blue's belief system be a factor in his initial decision to forgo the treatment necessary to save his life? Does Dr. Goodfaith have to respect Mr. Blue's beliefs if Dr. Goodfaith doesn't agree with them?