Patient autonomy

If a patient has been declared to be unable to make medicine decisions for himself, and thus is not consentable - what happens if the patient has occasional periods of lucidity? We were assisting in the lumbar puncture of a rather severely demented elderly patient, yet at times I thought his words made some sense. The procedure was rather lengthy due to the presence of large, venous stasis ulcers on his legs making it difficult to turn and position him. At first he was cooperative but clearly not quite understanding what we were about to do. When we finally began with the local anesthetic, he started to complain and wanted us to stop.

Should we stop? It sounds like a reasonable request - in fact, if he had been any other patient who had been deemed competent we would have been forced to stop. But I guess since it was also rather clear he didn't really understand the rationale and the need for the procedure, it would be unethical to listen to him and stop since that's not really an informed decision, is it?

Yet, it seems rather incongruous, to say the least, when he has some semblance of rationality, to completely disregard his demands. We tried to make him more comfortable, including keeping him informed as to the progress, but it was a slow output tap and collecting those 4 tubes took much longer than I had anticipated (note to self - never say, "almost done" to the patient - it just makes them much more anxious). In the meantime, the patient had began to threaten us verbally - saying he's calling the police and will "see [us] in court!". Wow - the first time I've ever been threatened by a lawsuit!

I've dealt with patients with dementia/delirum before, and it was rather easy - you kind of just ignore they non-sensical babble or talk along with them but not really listening to the content. In Winthrop, I've had many an alcoholic hepatic encephalopathic patient who had to be strapped down to the bed, but they were, for the most part, benign. They would obviously request that the restraints be removed, but that decision was not mine to make so that made interactions with them so much the easier.

Being an active participant, however, in this invasive procedure, made matters rather different/difficult. I'm now personally, actively, restraining the patient, in a way (more for his own safety given that he's got a nice sized needle sticking out his back) despite his protests. It's uncomfortable, and goes against the doctrines of medicine: Primum, non nocere (First, do no harm).

Harm whom? Clearly, the patient. By whose standards? Ah - that's the tricky part, no? Is the decision made by the omnipotent/omniscent physcians? As a collaborative agreement between the patient and the doctor? Or, in this case, between the healthcare proxy and the physcians? Where then does the patient fit into all this?

I guess one would argue that as the patient had, previously in his right mind, appointed a healthcare proxy for situations just like this, he is represented virtually through the proxy. Yet how often is it that the health care proxy is a close loved one of the patient? Don't you see a conflict of interest there?! Just look at the past cases involving persistent vegetative state patients and the conflicting interests of familys/spouses/etc.

Perhaps it's time to re-examine the idea of a health care proxy...or perhaps it's time to educate the public that sometimes, choosing your own spouse/close family as a proxy isn't the best idea...