Q: If Ms. R. has a cardiac arrest in the ER, should you comply with the patient's stated wishes?

A: Although Ms. R. is reportedly demented, her sensorium is clear, and based on what she has said so far, she has clearly thought about these issues before, and her stated wishes appear to be rational and internally consistent. It is important not to assume that she is globally incompetent - the key issue here is whether she is able to make an informed decision about the treatments under consideration at this time.

QUESTION #2:

Q: What other issues should be clarified with Ms. R. at this point?

A: In addition to what Ms. R. has already told you, you should try to establish whether she would agree to be hospitalized and to receive aggressive care (e.g., thrombolytic agents) as indicated if it appears she is having another heart attack.

Q: What should the EMS personnel do?

A: IMPORTANT: The answer to this question is based on guidelines established for EMS personnel by the Washington State Department of Health. Policies for appropriate responses to cardiopulmonary arrest situations by emergency personnel may vary between states, therefore it is IMPERATIVE that EMS personnel verify the requirements within their own state prior to an actual emergency.

In this case, if on-scene EMS personnel are unable to persuade her daughter to change her mind, established protocols for Washington state direct EMS personnel to start cardiopulmonary resuscitation (CPR), then contact the physician supervising EMS activities for further guidance. The physician who subsequently manages the emergency should respect the no CPR directive and order cessation of the resuscitation effort.

QUESTION #4:

Q: Bonus question: Can you think of some possible explanations for Ms. J.'s sudden deterioration?

A: Possible causes of Ms. J.'s presenting symptoms and circulatory collapse include (but are not limited to) acute myocardial infarction, possibly complicated by papillary muscle rupture, ventricular wall rupture with pericardial tamponade, or septal perforation; dissecting aortic aneurysm; and massive pulmonary embolism. Aortic dissection is suggested by the character of her chest pain, which radiated to the back. Right ventricular infarction could cause severe hypotension, and if pulseless electrical activity were present and resuscitation were to be attempted, an immediate trial of volume resuscitation could be lifesaving.

Copyright 1999, 2000 David A. Gruenewald, M.D. and Kayla I. Brodkin, M.D. All rights reserved.