AboutRonald Levy, M.D. Expertise Associate Professor of Anesthesiology, University of Texas Medical Branch at Galveston. I am a board certified anesthesiologist who can answer all questions related to any type of Anesthesia with the exception of Pain Management.
Question QUESTION: Hello,
I was recently intubated following an episode of several seizures. I was able to tell them I didn't want to be intubated no matter what - have been through it before - at any rate, I guess I seized again and they made the decision to intubate me. I was post ictal, but very much aware of what was happening. I felt the paralytics take effect first and actually felt them intubate me which was a terrifying feeling despite knowing what was going on (I work within the emergency medical field). I later spoke with the doc regarding both the issue of 1. I didn't want to be intubated, so why had he done it when I expressly stated otherwise and 2. why was I aware? He stated I was hypoxic and couldn't make decisions for myself (though I have stated many times in a non post ictal state I would not want to be intubated) so they acted in "my best interest" and that they thought I was post ictal enough that sedation shouldn't need to be required. What are your thoughts on this? Was the doctor right in his assessment of a mental state and can a doctor over rule a patient wishes like that and also is there any reason why he should not have given sedation? Thanks for your answers in advance.
ANSWER: The issue of self determination is a tricky one. If he is your doctor and knows your wishes, then he cannot intubate you (with the mutual understanding that you may die). If the doctor does not know you and there is no written health care proxy, then he will do what is in your best interest and intubate you. I suggest carrying a copy of your health care proxy and DNR documents with you (if that is your wish). As for being post ictal, you probably were not sedated enough but by the same token, most ER docs will not give medications for sedation for an emergency intubation. An anesthesiologist might, but there are reasons not to sedate in these cases. The main reason is that, if they can't intubate you, at least you will breathe spontaneously. I am sorry that you had such an unpleasant experience but from our standpoint, protecting the airway (and preventing aspiration) often overrules the discomfort the patient might feel because the consequences of aspiration are much worse.
Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston
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QUESTION: THank you for your prompt answer. Obviously this doctor was not my primary care doc and would not have had the documentation regarding my wishes, though I expressly stated them to him when we first got to the ER. I understand the implications, however after having been intubated previous times and having performed it on several patients, I came to the determination I never wanted that done to me again (with the exception of a surgical setting). To me it seems cruel to paralyze a patient without giving any sedatives at all, even once on the vent. What would be the contraindications to sedating a patient other than unable to perform a neuro exam following intubation? I know airway protection is primary concern, and I can appreciate that, but my curiosity came from can a doc specifically over rule a patient when they say "I don't want something"? Thank you again for your response.
Answer Once a patient is intubated, they should be sedated (unless there is a specific reason not to). But if you sedate a patient prior to intubation, you risk taking away their respiratory drive so that, if you can't intubate them or mask ventilate them, a surgical airway is necessary. Complicate that by someone who is post ictal and you are setting up for a potential disaster. As for overruling you, in theory he shouldn't be able to (that is considered battery) but most judges will side with the doctor if he claims that you were not of sound mind and that he would rather err on the side of conservative. Imagine the alternative where a patient says "don't intubate me", the doctors complies, the patients has an adverse event and the family later says that the patient was not acting normally. The liability, guilt, etc would be much worse. So in general, if the doctor is acting in good faith, the law will usually be on his side.
Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston
