Abstract

In lieu of an abstract, here is a brief excerpt of the content:Side Stepping The Issues: Disappointment With An Ethics Consult For A Medically High Risk PatientBrent R. CarrMonths of severe symptoms were a blur—hour after hour of suffering. Sleep is her only respite. Her 5-word diagnosis, “treatment-refractory depression with anxious distress,” seemed too orderly, like a flattened 2-dimensional strip of ribbon that simply ironed out all the chaos and confused distress roiling within her. Anyone entering the psychiatric unit early in the morning could hear her near-breathless sobbing, calling for nursing help, repeatedly pleading to anyone who would listen that she was dying. By afternoon, her wheelchair would be situated off to one side of the milieu to prevent agitation of other [End Page 13] patients. From there, she would summon them with small gestures or brief, incessant outbursts to save her, that her body was decaying, withering before them. Such is the torment of nihilistic delusions. She flailed her arms, rocking back and forth, lamenting that no one would help. Although she possessed full leg strength, she refused to stand from the wheelchair, fearing collapse. These distressed pleas were sustained well past each dinner, the anguish echoing from her room, and during her evening shower. Sometimes a pillow-muffled sigh and silence would disclose when her torments became engulfed in sleep.Two years prior, she had a similar episode that lasted almost 3-years. It had failed to respond to months of psychotherapy and more than 15 medication trials. That time, she had cried with happiness after the mental illness went into full remission after only a three-week course of electroconvulsive therapy (ECT). She described this as her miracle. But as miraculous as the ECT was for her, it was problematic. She is a high-risk patient with ongoing hypertension and Wolff-Parkinson-White Syndrome, a condition that leads to an inappropriately fast pulse from aberrant electrical pathways in the heart. During the final week of ECT, she experienced a marked blood pressure surge that led to severe cardiac pathology—Takatsubo’s cardiomyopathy. This is also known as “stress cardiomyopathy” or “broken heart syndrome,” befitting the vexed emotional state she had been in. The cardiomyopathy resembled a myocardial infarct, and it took several months for her to fully recover. Unfortunately, this prevented the use of ECT as a relapse prevention treatment. By one-year post-ECT, her systolic left ventricular dysfunction had resolved, and her ejection fraction (the heart’s pumping efficiency) had normalized.Now, once again, she was treatment-resistant, and ECT was the treatment of choice. The risk stratification for ECT encompassed her prior Takatsubo’s cardiomyopathy, which has a small but known chance for recurrence. This made her a high-risk patient. This risk was convoluted even more by her depression-induced psychosis, wherein she believed that she was dying, that meds were poisoning her, and that ECT would kill her from a heart attack. Before the psychiatric team consulted the ECT service, a mental health court had already ruled regarding her lack of capacity for her medical decisions. The court had authorized her husband as her proxy with authority to consent for her medical care, including for ECT. My role in this case was as the ECT proceduralist from the neuromodulation service who had been consulted by the primary team. The husband was an informed individual and signed consent for ECT. These events all coincided with the primary attending’s departure on scheduled leave. There was now a new covering attending.The resident psychiatrist was apprehensive about ECT and deliberated that the patient was at least able to identify potential risks of ECT—even if exacerbated by a nihilistic delusion. The resident speculated that perhaps the patient should at least be able to refuse ECT, given her previous cardiomyopathy. The newly arrived attending deferred a response regarding her concern and stated it had already been decided by the “team.” This amplified doubt. The medical students sensed the resident’s apprehension and felt confused about whether the patient should receive ECT or not. This dynamic quickly spilled over into nursing discussions, where some were now hesitating about the decision. The cohesiveness of the psychiatry treatment team was compromised...