When Physicians Disagree: A Case of Nonconvulsive Status Epilepticus

CONTINUUM: Lifelong Learning in Neurology
October 2011; Volume 17(5) Neurologic Consultation in the Hospital; pp 1119-1123

The practice of neurology presents a series of ethical challenges for the clinician. These rarely have simple or straightforward solutions, but require careful consideration by the neurologist. This section of Continuum, written by colleagues with particular interest in the area of bioethics, provides a case vignette that raises one or more ethical questions related to the subject area of this issue. The discussion that follows should help the reader understand and resolve the ethical dilemma.

Hixson, John David MD

Address correspondence to Dr John Hixson, University of California, San Francisco, 400 Parnassus Avenue, Campus Box 0138, San Francisco, CA 94143, jdhixson@yahoo.com.

Relationship Disclosure: Dr Hixson has received personal compensation for medical record review from Lumetra Healthcare Solutions, Inc. and for expert testimony.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Hixson reports no disclosure.

A 32-year-old woman presented with episodic speech problems over the past month. The neurologist had observed three of the episodes, during which the patient had notable difficulty producing even simple speech but was able to follow basic commands. The neurologist admitted her to the hospital for continuous EEG monitoring for suspected nonconvulsive focal seizures. A brain MRI showed mild T2 signal change in the left temporal lobe without enhancement. Aggressive antiepileptic treatment with sequential medications at maximum tolerated doses was not successful. A PET scan demonstrated a hypermetabolic focus in the left temporal region. Limbic encephalitis was suspected. Despite maximal therapy, the patient continued to have multiple seizures each hour, with increasing frequency and duration. Between events she was relatively unaffected, although she was distressed by the episodes and asked the neurologists to do everything they could to control the seizures. With a diagnosis of nonconvulsive status epilepticus (NCSE), the neurology team discussed elective intubation and induction of a pharmacologic coma with midazolam and propofol. There was initial disagreement among the team because of the risks and the uncertain efficacy of this approach; however, the attending physician decided that aggressive therapy was warranted. The plan was discussed with the patient and her family, and they provided consent. Regrettably, treatment was not successful, as the EEG showed episodic, monomorphic, rhythmic delta activity over the left temporal region that was interpreted as seizure activity. The addition of pentobarbital was considered.

At this point, a new attending neurologist assumed responsibility for the inpatient service and criticized the decision to induce coma as unproven, unsafe, and a waste of health care resources. The resident team was invested in continuing treatment, and the patient's family was reluctant to stop treatment because the patient had made them promise that they would continue treatment until the seizures stopped. The new attending neurologist, without speaking to the patient's family, wrote orders to begin reducing the midazolam and propofol so that the patient could wake up and be extubated. The patient's nurse and the senior resident on the service objected and insisted that treatment could not be changed without the family's permission.

Differences of opinion are common in the practice of medicine. Even in the era of evidence-based medicine, there are substantial limitations to the application of the scientific literature and guidelines to specific patient scenarios, and individual physicians may view the risk/benefit ratio differently. This situation commonly occurs in the outpatient setting when patients obtain a second opinion; however, unless the patient makes the choice to end the relationship with the previous physician and establish a relationship with the new physician, neither the physician nor the treatment changes. Conversely, in inpatient settings where the attending physician rotates on a schedule, the physician assigned responsibility for the patient's care can change without the approval of the patient or family. In most instances, this transition is seamless and the treatment plan is continued; however, when the two attending physicians have significant differences in opinion, as in this case, an ethical dilemma arises. This case raises several relevant ethical questions:

1. Does the new attending physician have any ethical obligation to continue the treatment plan that the previous attending physician had promised to the patient and family?

2. Does the principle of informed consent apply to decisions to stop treatment, or is it limited to the initiation of treatment? Can the attending physician stop treatment without consulting the family?

3. Other than to refuse to comply with the attending physician's orders, what options are available to the patient's nurse and the senior resident?

The patient and her family were involved in the original treatment decision and were fully educated about the risks and benefits. Thus, regardless of the new attending physician's opinion, the treatment decision has already been made with full informed consent. Based on the principles of autonomy and respect for persons, a strong argument in favor of continuing treatment exists.

Of course, if there was a clear error in the diagnosis or treatment, the new attending physician would have an obligation to correct this. In this case, however, the decision to induce coma is reasonable. Burst suppression for the treatment of NCSE is well described,1,2 although considerable risks are associated with the use of anesthetic agents.2 Further, good evidence exists that refractory NCSE causes neuronal damage, especially if it is protracted or resistant to initial attempts at burst suppression.3,4 The diagnosis of NCSE portends a more favorable outcome than convulsive status epilepticus, and the treatment of the underlying disease process (limbic encephalitis) could result in spontaneous remission of the seizures. The decision to treat aggressively is supported by the principle of beneficence. If the patient and her family were made aware of the risks, as well as the potential but uncertain efficacy of treatment, then the original plan was medically justified and ethically permissible.

In this specific case, the decision is no longer whether to initiate a therapy but whether to stop, change, or continue it. Given the patient's lack of response to the induced coma, the balance of benefits and risks has changed. Status epilepticus that has proven refractory to initial attempts at burst suppression is likely to remain resistant and carries a worse prognosis.1 Thus, it is reasonable to invoke the principle of nonmaleficence, as the risk of pneumonia, hypotension, gastroparesis, and hospital-acquired infections may be more likely than the chance of treatment success. The ethical argument to continue treatment primarily out of respect for the patient's original choice may no longer be valid, as the medical circumstances underpinning the original informed consent discussion have changed substantially. Further, the shared decision-making model is applicable, as Dr John Luce describes:

Physicians using this model are expected to discuss the nature and likely outcome of a given illness, explore the ramifications of forthcoming decisions, determine patient values, confirm that patients and families understand the information provided them, discuss preferred roles in decision-making, and achieve consensus about treatment courses that are most consistent with patient values.5

Based on the shared decision-making model and the principles of informed consent, therefore, a strong ethical argument exists that the attending physician, the residents, and the nursing team should meet with the family to review the medical circumstances (ie, the response to therapy) and reconsider treatment options.

In this case, is the continuation of treatment futile? Futility arguments are usually considered when the patient's condition is so dire that treatment can neither reverse the patient's underlying disease nor prevent the patient's imminent death or a very poor outcome (eg, vegetative state). Remaining in intensive care uses considerable resources, and a distributive justice argument is that continuing futile care detracts from the care of other patients.6,7 However, some have argued that resources should not factor into individual medical decisions.7 Bernat notes that futility has both a quantitative component (ie, the likelihood of success) and a qualitative component (ie, the quality of the outcome).8 In this respect, the failure of induced coma would seem to make it futile; however, the quality of the patient's outcome with continued treatment would be reasonably good, provided the treatment has no serious complications. Further, despite the initial treatment failure and known risks, treatment with pentobarbital may still be successful. Considering the patient's age, premorbid good health, and the nature of the deficits prior to treatment, the argument of medical futility is not supported in this case.

The predicament of the senior resident and nurse, who disagree with the new attending physician's actions, also presents a significant ethical dilemma. More than a difference of opinion between colleagues, this situation presents a conflict between health care professionals at differing levels of the decision-making and training hierarchy. Disputes between attending physicians and the health care team are not uncommon,9-11 and in most cases the nurse or resident defers to the attending physician. In a sense, this practice of "due deference" is justified: the attending physician is ultimately responsible for the patient's care and thus has the final authority in the decision-making process.9 Further, the resident is a trainee; respectfully observing the different philosophies of attending physicians is an important aspect of learning clinical skills and developing an individual style of practice.

However, from the purely ethical perspective, the nurse and resident may still feel obliged to intervene in this patient's case. Because the attending physician is often charged with evaluating trainees and the health care team, the resident and nurse are placed in a difficult situation with a personal "stake" in the ethical quandary. The risk is that refusal or objection by the resident and nurse could be interpreted as insubordination, and the challenge is to make use of existing mechanisms for resolving disputes within the health care team. Unfortunately, the nurse and resident usually have few formal mechanisms to use.10,11 The need for educational sessions on ethics and conflict resolution in both traditional residency training curricula and ongoing faculty development series has been recognized.11 In this particular situation, the nurse and resident may suggest involving the original attending and the residency director in a group discussion of the case. Alternatively, considering the scenario is highly charged and the patient's care and outcome are at stake, an ethics consultation would be appropriate. In the future, incorporation of an "ethics grand rounds" may be useful for both resident education and resident-attending communication.

How can the dilemma in the case be resolved? Communication is the key. A frank and respectful discussion between the attending physicians is critical, with the first physician outlining the initial thought process and conversation with the patient and family. This initial dialogue should ideally occur with the entire health care team prior to meeting with the family. Open tension or argument should be avoided, especially in front of trainees and the patient or family members.12 However, considering that both treatment approaches are reasonable, it is also important to disclose to the family that differing professional opinions exist, which is consistent with the principles of informed consent. When both opinions can be supported through evidence, it is instructive for all to participate in the discussion, which should always include the patient (when possible) and family members. It may be helpful to have both of the attending physicians attend a family meeting to present the treatment options and the rationale supporting each choice. If the family is given a complete clinical picture, they will be in a better position to decide on a treatment approach with the patient's goals of care in mind.

A hospital ethics consultation should also be strongly considered. Ethics committees have been present within hospitals for decades and have gained further prominence. The use of an ethics committee consultation is a "shared decision-making" or "due process" approach.5 The goal of this approach is essentially mediation. In this particular case, the ethical dilemma is a disagreement between physicians, rather than a question of medical futility. In resolving the dispute, it is important to focus on the patient's interests. The ethics consultation team, as disinterested parties to the patient's care, may be capable of envisioning options that the health care team has been unable to see because of their personal involvement in the conflict.12

1. Rabinstein AA. Management of status epilepticus in adults. Neurol Clin 2010;28(4):853-862.

2. Jordan KG, Hirsch LJ. In nonconvulsive status epilepticus (NCSE), treat to burst-suppression: pro and con. Epilepsia 2006;47(suppl 1):41-45.

3. Wittman JJ Jr, Hirsch LJ. Continuous electroencephalogram in the critically ill. Neurocrit Care 2005;2(3):330-341.

4. Claassen J, Hirsch LJ, Emerson RG, Mayer SA. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia 2002;43(2):146-153.

5. Luce JM. A history of resolving conflicts over end-of-life care in intensive care units in the United States. Crit Care Med 2010;38(8):1623-1629.

6. Lonergan R, Kinsella K, Duggan M, et al. Discontinuing disease-modifying therapy in progressive multiple sclerosis: can we stop what we have started? Mult Scler 2009;15(12):1528-1531.

7. Niederman MS, Berger JT. The delivery of futile care is harmful to other patients. Crit Care Med 2010;38(10 suppl):S518-S522.

8. Bernat JL. Ethical issues in neurology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2008.

9. Levi BH. Ethical conflicts between residents and attending physicians. Clin Pediatr (Phila) 2002;41(9):659-667.

10. Shreves JG, Moss AH. Residents' ethical disagreements with attending physicians: an unrecognized problem. Acad Med 1996;71(10):1103-1105.

11. Rosenbaum JR, Bradley EH, Holmboe ES, et al. Sources of ethical conflict in medical housestaff training: a qualitative study. Am J Med 2004;116(6):402-407.

12. Williams MA. Process and benefits of ethics case consultation. Presented at: 59th Annual Meeting of the American Academy of Neurology; April/May 2007; Boston, MA.