29 August 2009

ACT Health seek permision to starve patient

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ABC news is reporting about an elderly, mentally ill patient who is on a hunger strike, psychotically believing he won’t die and it will bring him closer to God. ACT Health, supported by the ACT public advocate which is his leagal guardian, are seeking permission from the supreme court to not force-feed him, and allow him to starve to death.

On the one hand, doctors are there to ‘do no harm’ and force feeding him will harm him and be ‘inhumane’. He has declared his wishes and the doctors want permission to abide by them.

On the other hand, allowing someone to starve to death seems inhumane also. This case has parallels to the recent case of a quadriplegic man in WA beign given court permission to starve to death, except that this man cannot legally give consent. He may have ‘clearly expressed his wishes’, but he is in fact not able to decide for himself.

UPDATED: Chief Justice Terence Higgins has ruled that the hospital must continue to force feed him. In a quote from the paper CT but which I can’t find online, he said the patient must be treated as though he “lacked consciousness or was a helpless infant” due to his inability to give informed consent.

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astrojax said :

something’s awry – the link to justice higgins’ judgement does not work…

It does, but only if you manually remove the final . character
Riotact’s link recognition has limits, and can’t tell jt.html from jt.html.
(Don’t attribute to conspiracy what can be explained by legitimate technical difficulties)

Proper link: http://www.courts.act.gov.au/supreme/judgments/jt.htm

something’s awry – the link to justice higgins’ judgement does not work…

Quokka: I think Higgins does address that – re-read paragraphs 45 through 48 in particular. It is clear that in the case of a patient unable to give consent, lack of parent or guardian consent does not necessarily make treatment illegal.

moneypenny2612 said :

For those interested, you can read Chief Justice Higgins’s full judgment at: http://www.courts.act.gov.au/supreme/judgments/jt.htm

Interesting reading. Chief Justice Higgins has ruled that not treating this man would be unlawful. However, he has not directly addressed the issue that providing treatment against the wishes of the guardian would also be unlawful (except in situations covered the common law, i.e, emergency situations where treatment can be provided without consent – presumably not every day of this man’s life would consitute an emergency situation!). This would seem to leave the staff treating him in a lose-lose situation where both treating him or not treating him are unlawful. Hopefully his guardian will decide to agree to treatment and make things a little easier, since it doesn’t seem that withdrawing treatment is a viable option.

Thanks moneypenny, indeed an interesting read. It certainly did canvass a broad range of decisions, and the reasons given for agreeing or disagreeing, and relevance to this case were worth a read too.

Sadly, I suspect this is a long way from the last we’ll hear of this particular case. Having worked in disability support, I can empathise with those in the situation of having to provide uninvited care to someone who cannot be reasoned with in any rational way regarding that care. The day to day ramifications would be immensely stressful to say the least. And I suspect the peg will become the physical focus of his efforts to remain unfed, with attempts to remove the device a real possibility.

At the same time, having lost my wife to cancer, and observed the benefit of ever increasing levels of pain relief in achieving a dignified death, I can empathise with those promoting this course of action.

The critical issue for me continues to be INFORMED consent, choosing a course of action from a position of complete understanding of the consequences of that course of action.

I think the most concerning thing here is that Higgins made a seemingly sensible decision

moneypenny2612 said :

For those interested, you can read Chief Justice Higgins’s full judgment at: http://www.courts.act.gov.au/supreme/judgments/jt.htm.

It’s a worthwhile read as the judge canvasses court decisions made in other states and other countries, which arose in a wide range of circumstances. Obviously it is a very difficult decision for both clinicians and the law.

Personally I find it scary that in this case the shrinks and the hospital ethics committee thought is was in-principle OK to abide by the death wish of an insane man.

after reading it – i think Justice Higgins made the right decision and yes it is scary that the professionals thought it was ok to abide by the death wish of a mentally ill man. well done higgins

moneypenny26125:58 pm 29 Aug 09

For those interested, you can read Chief Justice Higgins’s full judgment at: http://www.courts.act.gov.au/supreme/judgments/jt.htm.

It’s a worthwhile read as the judge canvasses court decisions made in other states and other countries, which arose in a wide range of circumstances. Obviously it is a very difficult decision for both clinicians and the law.

Personally I find it scary that in this case the shrinks and the hospital ethics committee thought is was in-principle OK to abide by the death wish of an insane man.

It’s worth bearing in mind that feeding this man in itself would not seem to be without serious risk. He is reported to weigh 41kg and to have not eaten for 2 weeks. Feeding in his current state would be likely to have a high risk of inducing refeeding syndrome (a dangerous metabolic condition that can occur when nutrition is provided to people who are severely malnourished – as an aside this was first described in WWII POW’s who died after they were refed following their rescue from prison camps). In elderly patients refeeding syndrome can have a mortality as high as 50%
http://content.karger.com/ProdukteDB/produkte.asp?doi=10.1159/000218162

Given that this man (and also his legal guardian) has not consented to treatment, continuing to treat him in the absence of a court order would expose the staff treating him to charges of at least assault, and possibly manslaughter if he were to die as a result of his treatment. I can see why they wanted a court ruling on how to proceed!

Hells_Bells742:25 pm 29 Aug 09

Don’t they go against people’s wishes suffering anorexia all the time? They are thinking food is the devil. Just a thought..

Clown Killer1:37 pm 29 Aug 09

Astro, I’m only being mildly facetious on this matter. I really do feel that we are passing judgement about mental state based on a divergence of views. The court seems to believe that choosing to starve yourself to death is evidence of madness. I would argue that simply having a view that is so wildly different from the common experience doesn’t really mean you’re mad.

but, ck, as the recent case in wa showed, it is precisely this patient’s lack of [mental] capacity to determine his best interests (given we live in a society that doesn’t condone murder) that take this course due to the patient being unable to ‘make decisions about his own life’… if he were of sound mind, perhaps he may have some sympathy (he’d have mine) to choose to terminate his own life, but i think we must act as a community to ensure someone with no such mental capacity isn’t assisted to die when we have no way to determine what his ‘sound mind decision’ may have been. there is no room here for speculation.

If they feel it’s OK to kill him, they should do so humanely, not by starvation.

Have to say I’m pretty much with Astro on this, critical point is capacity. The debate about euthanasia doesn’t even begin until you’ve established “of sound mind”. And surely a mild anaesthetic to assist in the feeding process is a far more reasonable approach than petitioning the court to allow a person to follow a course of action that they do not understand will lead to their death.

Clown Killer10:45 am 29 Aug 09

I disagree Astro. It is my view that the court has plainly made a judgement of convenience believing that it has the authority to decide that this man, regardless of his mental state, does not have the right to make decisions about his own life.

Continuing with the current treatment is tough on the medical staff – CT said they have to strap him down incredibly tightly to stop him pulling out all his tubes etc. Continuing with this seems bad, but ceasing to feed is also bad. Hence the lack of comments I think – there just isn’t a good option to advocate for.

i dunno, i thought this would be a divisive issue with a number of people genuinely, or for their own stirring reasons, posting in strong support of euthanising this chap – we get [or got] a hundred + posts on other topics where ‘justice’ is at issue and here it is writ large but no-one has an opinion…

i’m glad the system has upheld common sense, for once.

astrojax said :

i’m surprised this thread is so bare of comment – i wonder if this is the way of the world post-jb?

I think its a sad situation and have nothing else to add than what I already have. What are you expecting people to say astrojax ?

“if he wants”, doves, is the critical point here.

‘wanting’, in its strictest sense, implies a capacity to do this is a sane and rational manner. a crazy person might ‘want’ to put their hand in a fire, but would you ‘want’ to let them? this person does not, from the reports (of course, i am not the consulting psychiatrist), have the capacity to ‘want’ such serious consequences that we should simply allow them to have them. as i mentioned above, i believe the community here has a strong duty of care.

so re your ‘apart from the mental illness’ – well, the ‘mental illness’ is quite enough for loud alarm bells to ring in this case and tell us much about any stated ‘desires’ he may have expressed.

i’m surprised this thread is so bare of comment – i wonder if this is the way of the world post-jb?

I believe he has a right to die if he wants, apart from mental illness, what else is he suffering from, if its cancer, I can understand, as it is very cruel and having to watch someone suffer is just terrible, the pain he has to endure.

Would anyone here let a suicidal person jump off a bridge if they could stop them?

You try and make a complicated situation into a simple one. The one in question could end up with physical harm or death no matter which way the decision goes. It’s hard to come up with a logical decision without the full story, as always the main points released in the media don’t come out with a definitive answer.

Given the facts presented, this gentleman has had a mental illness for a long time and appears to be in this state for the majority of his living life, I would guess that the medication available doesn’t work particularly well and is brought on worse after he starves himself. The statement that he starves himself for weeks then improves I don’t think is an indication that if they keep at it that he will improve and not want to starve himself anymore, as it doesn’t appear to last long.

When someone is so intent on doing/not doing something, they will find a way no matter what. I’d say stop force feeding him, leave him food and if he doesn’t eat it, so be it.

Lets hope someone is there for this one if needed.

well, they are, it seems, just that there seems some confusion over what they should do. as thumper notes, whatever it takes, seems about right…

and sorry for you, whatsup. must have been a terrible experience. ; ( hope you are ok since?

Would anyone here let a suicidal person jump off a bridge if they could stop them?

I’ve witnessed a mentally ill person take their own life. I wasn’t physically close enough to try and stop them but of course I wanted to. Lets hope someone is there for this one if needed.

caf said :

This appears to be the concern:

They gave evidence saying that when they used gastric tubes to force-feed the man he resisted violently and pulled them out.

His psychiatrist, Dr Judith Raymond, told the court she believes the amount of force required to keep him alive is inhumane.

Is there a reason why sedating him until the psychotic episode is over isn’t a possibility?

The doctors say that his psychotic fasting episodes have lasted several weeks in the past. That’s a long time to restrain/sedate someone, especially as he will almost certainly have another episode, they say.

Justice Higgins will earn his money pondering over this one.

Is this man able to make a rational informed decision given his mental illness ? I don’t know but I hope there are the right people around him with a thorough understanding of the details to ensure his best interests are looked after.

‘able’, not “bale”

the op mentioned the wa case – i contend that the parallels end with that case in the point that he was of sound mind and bale to make rational decisions as to the chances of his otherwise longevity and well being for that quantifiable period, where this chap seemingly has no such capacity and to acquiesce to these stated desires would be tantamount to community murder. we, as a community, have a duty of care to see that this man is not taken at his word, which is demonstrably (at least allegedly) unsound.

jesus notwithstanding.

he’s defianatly not able to make decisions in his best interests so someone else should and it doesn’t involve starving him to death. i’m sure we don’t know all the facts therefore it makes it even harder to say what should/needs to be done. If he has improved with medication in the past why not now? i guess i’m not one to give up especially with people who have mental illnesses. hard indeed however he should be helped to recover

This appears to be the concern:

They gave evidence saying that when they used gastric tubes to force-feed the man he resisted violently and pulled them out.

His psychiatrist, Dr Judith Raymond, told the court she believes the amount of force required to keep him alive is inhumane.

Is there a reason why sedating him until the psychotic episode is over isn’t a possibility?

Pommy bastard said :

BUT! What if Jesus has told him he does not need to eat or drink? Who are we to question Jesus, or indeed act against his will?

This could be the evidence that us Athiests have been waiting for. If God keeps this man alive without food then hallelujah! But anyway, Australia is apparently a Christian nation of sorts so why isn’t the majority of God-fearing Australians celebrating this man’s wishes and believing that God *will* save him? Surely this cannot be considered suicide as he has the belief he will be with God. Isn’t this a matter of faith? And sure, for Theists, death will bring them closer to God.

Seriously though, I feel concerned for the welfare of this man, not because he is not being fed –that is a separate issue– but because he is being used (as Granny rightly states) as a precedent for dealing with the mentally ill who cannot make informed decisions in situations that are detriment to their health.

Whilst I can see both sides, I would consider this to be a dangerous precedent. People with mental illness are frequently suicidal whilst having an episode, where they are not while the condition is being managed. What they want while unwell is not necessarily what they would choose at other times, and religious delusions often go hand in hand with mental illness. I think it is more important to assist them to recover than to assist them to suicide.

Keep a schooner of cold beer on his bedside table and see how long he can last…

“I swear, it just evaporated into thin air!”

Pommy bastard said :

BUT! What if Jesus has told him he does not need to eat or drink? Who are we to question Jesus, or indeed act against his will?

Fair point; with a couple of very special caveats, you can’t go to heaven if you don’t ever die.

Members of our community should discuss these matters and demand to understand the issues and facts. Suggesting this sort of thing should be farmed out to the medicos, guardians, judiciary or (the gods forfend!!) the Canberra City Council to decide, needs to take a good hard look at how democracy is supposed to work.

Clown Killer3:49 pm 25 Aug 09

My understanding is that the public advocat is seeking to ensure that the traeting doctors are not legally exposed if they follow the patients wishes. Still I doubt that these people are paid enough for the work that they do and the decisions that they have to make.

Pommy bastard3:17 pm 25 Aug 09

BUT! What if Jesus has told him he does not need to eat or drink? Who are we to question Jesus, or indeed act against his will?

PBO said :

Without having all the information and we wont ever have it, this is something that non of us have any say over aside from the patient, his doctors and family (if he has them).

Rubbish!

As a society we have a say (through the court) in how we treat our most vulnerable.

Since the public advocate is his guardian, I doubt he has family, so the public has a say as his guardian.

Without having all the information and we wont ever have it, this is something that non of us have any say over aside from the patient, his doctors and family (if he has them).

I agree with poptop and he should be allowed to have pain relief.

Clown Killer2:46 pm 25 Aug 09

A very dificult issue indeed. I’m glad I’m not the one having to call the shots.

This is the sort of discussion that is going to get heated.

This is not about doctors doing harm, this is about Duty of Care and letting doctors not intervene.

For my 2 cents, the man has lived with his illness for a really long time and seems likely to have been unhappy, unwell and afraid for most of that time. If being allowed to make his own choices will give him any peace of mind at all, I reckon we should let him get on with it.

I reckon they should be permitted to provide pain relief though.

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