Title: DNR
Original airdate2/1/05
Episode: 109
Synopsis: A brilliant trumpeter confined to a wheelchair develops pneumonia and signs a DNR to prevent a slow death from his ALS. House doubts the ALS diagnosis.
Patient: John Henry Giles
Initial symptoms: difficulty breathing
*****Spoilers below*****

Differential diagnosis:


A group of young musicians wait in a recording studio for John Henry Giles, a legendary jazz musician. He arrives very late, in a wheelchair pushed by his companion. He begins to play his trumpet, but experiences extreme difficulty breathing. His trumpet falls to the floor as his companion rushes to his aid, and one of the musicians calls an ambulance.

House barges into Cuddy's office demanding John Henry's case. House is intrigued by John Henry's paralysis, though Cuddy tells him the only aspect of the case important to the hospital is simple (and boring) lobar pneumonia. Cuddy informs him that John Henry's inability to walk is already being treated by Dr. Marty Hamilton of California, with whom Foreman did his residency, and has asked Foreman to treat John Henry's pneumonia.

Foreman asks Chase about John Henry's O2 sats, which are in the 90s on a nasal cannula, and John Henry is not coughing up much sputum.  Foreman decides to keep John Henry on broad-spectrum antibiotics, and since he shows septic physiology, he orders tests to measure his adrenal and thyroid function.

House blocks the team's path as they try to leave, asking what Foreman is going to do about John Henry's paralysis. Foreman informs him that the paralysis has already been diagnosed by Dr. Hamilton as ALS, or Lou Gehrig's disease.  House commandeers the white board, and asks the team for alternatives. Chase suggests Guillain-Barré, which Foreman shoots down because the progression of the paralysis was not symmetrical. Cameron suggests transverse myelitis, for which Foreman says John Henry tested negative for, along with masses and AVMs. Chase them suggests multifocal motor neuropathy. House likes this idea, and asks if Dr. Hamilton ever tried IVIG to treat John Henry. Foreman says he did not, due to John Henry's negative MRI. House ask for a new MRI. Chase and Cameron begin to move, but Foreman reminds them that it's his case, not House's. Foreman insists ALS is the best diagnosis due to the progressive paralysis and the pneumonia would be expected, as well.

While Foreman is drawing blood, John Henry asks Foreman if his breathing problems are due to the ALS. Foreman says they are. John Henry tells Foreman that he likes Dr. Hamilton, but it's become clear that his experimental treatment is not working.  Foreman suggests an MRI, but John Henry is dubious of an MRI for pneumonia. Foreman tells him that House thinks they should test for other things. John Henry is familar with House's reputaion for obsessiveness.

John Henry asks Foreman who he believes his right, and Foreman tells him that ALS fits all his symptoms. John Henry decides against the MRI, and asks to sign a DNR before he becomes incapacitated.

Foreman finds House lying on the floor of his office listening to John Henry's albums. Foreman tells House of the DNR, which House doesn't find surprising since Foreman did not tell John Henry he might not have ALS. Foreman says he started John Henry on IV steroids and Synthroid. House says if the case was his, he'd add IVIG. Foreman reminds him that John Henry doesn't want anything done, to which House replies that the DNR prevents resuscitation, not treatment.

Foreman orders John Henry's steroid dosage increased and also orders IVIG. While House is seeing a clinic patient, he receives a page for a Code Blue for John Henry, who is now gasping for air. Chase notes that John Henry's O2 sats are dropping and his breath sounds are "junky." Cameron asks if it is a mucus plug, but  Foreman says it is sludging from the IVIG preventing blood from getting to his lungs.  Cameron orders heparin by IV push, though Chase thinks John Henry will die before it has a chance to work, and needs to be intubated immediately. Foreman points out that they can't, due to the DNR.
He arrives in John Henry's room to find that John Henry's O2 sats are in the 70s, and John Henry has been struggling to breathe for ten minutes due to the IVIG.

House orders Chase to intubate John Henry. Chase can not, so House does it himself and calls for a bag, despite Foreman's vehement protests. John Henry's companion enters the room, and asked what House has done, to which Cameron replies he saved John Henry's life.

John Henry is now stable on the ventilator. House notes that the IVIG made him worse which means multifocal motor neuropathy was the wrong diagnosis, and seeks new ideas. Foreman is outraged at House's violation of John Henry's DNR. House tries to suggest that John Henry was not competent to sign the DNR due to depression caused by his low thyroid levels. Foreman brushes the suggestion aside, know that even House didn't believe it.

House reasons that John Henry signed the DNR to avoid a slow, torturous death from ALS, but the breathing problem had nothing to do with the ALS. Foreman counters that House didn't want John Henry to die only because it would have been his own mistake that killed him, though House notes that the error was actually Foreman's responsibility, since Foreman is in charge of the case.

After Foreman storms angrily from the room, House ask why John Henry's lungs would have gotten worse. Chase suggests vasculitis, though it is unlikely to occur in both lungs. Cameron suggests Wegener's granulomatosis. Just then, House is served with a restraining order preventing him from going within 50 feet of John Henry, and is also informed that he is to be charged with battery.

House asks Cameron to test John Henry's blood for C-ANCA. House asks Chase if he is still doing bronchoscopic suctioning for John Henry's pneumonia, which he is, every four hours. House tells him to get a biopsy to confirm Wegener's next time he does this.  He also tell him to move John Henry to the second floor ICU, which is directly above the clinic, so he can avoid clinic duty.

Cuddy asks House if he needs a lawyer, and informs him that Dr. Hamilton is flying in from California to "pull the plug" on John Henry, at John Henry's request. House says he does need a lawyer.

In the courtroom, House's lawyer argues that John Henry must stay on life support against his will because his death would violate House's Sixth Amendment right to face his accuser. He also argues the DNR might not be valid, depite being witnessed by Foreman. House interrupts the legal proceedings to ask the judge if he has any history of heart disease in his family, as he noticed clubbing of the judge's fingers. He advises him to see his doctor, lest he keel over like Bart Giamatti. The judge is now paying more attention to his fingers than John Henry's lawyer, and wins the round.

House returns to the hospital, and Chase tells him the biopsy shows only inflammation. House orders Cytoxan. Cameron and Chase are reluctant to violate John Henry's wishes, and risk their medical licenses, so House starts the medication himself.  As he leaves John Henry's room, House runs into Marty Hamilton. He has a brief conversation with House, pointing out that he tested for, and ruled out Wegener's.

Foreman arrives and shares a friendly greeting with Dr. Hamilton. House reminds Dr. Hamilton that he has a court order keeping John Henry alive. Dr. Hamilton tells House that the charges have been dropped, so he no longer has an accuser to face, and that 
John Henry's decision is to be taken off the ventilator.

John Henry's companion kisses him goodbye, and Dr. Hamilton removes the ventilatior while House and Wilson watch from the hall. Everyone waits, but John Henry continues to breathe on his own. House now knows he was wrong about Wegener's.

John Henry continiues breathing on his own, but now he can't move one of his arms. Cameron believes the progression of the paralysis confirms the diagnosis of ALS, but House thinks the paralysis of the arm and legs are not related. Cameron then suggests a stroke since blood clots are common in paralyzed patients. House orders an MR angiogram to look for an embolic stroke, but Foreman notes that John Henry is not House's patient, and John Henry wants nothing to do with him.

House goes to John Henry's room to try and talk him into treatment. House speculates as to why John Henry signed the DNR, though he acknowledges that John Henry's life "sucks more than most." He tries to strike a bargain. If John Henry will allow House to find out what's wrong with him, House will assist him in dying if he still wishes it. John Henry declines telling House that his life is no longer worth living if he cannot play music. Music is his "one thing," as medicine is for House. The cost of such a gift is everything else that other people have, leaving nothing when the gift is gone.

House digests this for a moment, and begins to wheel John Henry's bed from the room, his reasoning being that if John Henry wants to die, he can do it anywhere, including an MRI machine.

While Chase and Cameron review the MRA and find a clot in John Henry's brain. Chase thinks it might not be too late to break the clot with tPA. Foreman tells John Henry that they want to start him on heparin. John Henry asks about the side effects of the treatment. Foreman tells him that because of the pneumonia, there a chance of an effusion, or bleeding into his lungs. John Henry is unwilling to risk further damage to his lungs. Foreman then suggests an embolectomy to remove the clot without risk to the lungs, but may kill him. John Henry agrees.

After the procedure,  Dr. Hamilton pages House to John Henry's room to tell him John Henry can now move his arm. House is irritated that Dr. Hamilton didn't just use the phone, but says he's glad the procedure worked, and pats John Henry on the leg. To everyone's surprise, John Henry felt the touch. John Henry now has feeling in his leg up to his calf.

Dr. Hamilton thinks his experimental enzyme replacement protocol is reversing the ALS, and House is convinced it's one of the drugs his own team has given John Henry. To figure out which one is helping, House stops all of them. Cameron objects, but House points out that John Henry is on antibiotics, anti-inflammatories, and steroids, and cannot stay on all of them indefinitely, since they will eventualy do more harm than good. His idea is to stop the drugs, and restart them again one by one. Foreman thinks House wants him to ask Dr. Hamilton to stop his drug therapy as well, but House thinks the other drugs are irrelevant.

Dr. Hamilton comes to House to ask which medications he's stopped giving John Henry, but House refuses to tell him. He is suspicious as to why Dr. Hamilton is asking, and goes to John Henry's room to find he has lost the feeling in his legs again. House orders John Henry put back on the steroids, which was the first drug he was given, and another MRI from the T-9 to the cauda equina. Cameron is startled by something on the MRI.

Chase and Cameron run back to House's office to show him they've discovered the cause of John Henry's paralysis, an intradural arteriovenous malformation which has been pressing on John Henry's spine. Foreman wonders how Dr. Hamilton could have missed it on the MRI, and House points out that it was not visible on the previous MRI due to the swelling it caused. John Henry was given steriods, which reduced the swelling, allowing the AVM to be detected. Once it is removed, John Henry will be able to walk.

After his surgery, and an unknown period of physical therapy, John Henry is able to leave the hospital, walking with a cane. He meets House in the lobby as he departs. He thanks House for his determination, and gives House his trumpet.


Diagnosis
:
arteriovenous malformation


Soap Opera
:
House seriously violates medical ethics by intubatung John Henry, thus violating the DNR. Foreman is outraged at House's behavior, and believes House should be more like Dr. Hamilton, who is not abusive and forgives mistakes.  House tells Foreman that what he perceives as "abuse" is actually accountability, which will make him a better doctor.


Clinic Patients:


Viagra man - comes to the clinic asking for the "blue pills." House tells him he doesn't need the blue pills, however, he needs to better manage the diabetes he failed to mention. House noticed the man's hands had no hair, indicating nerve damage. He also noticed his shoes were too small, denoting a lack of sensation in his feet, and powdered sugar on his pants indicating an unwise affinity for donuts. House writes him the prescription anyway, with the caveat that if he has heart disease from the diabetes, the pills will kill him. Other than that, he should go enjoy himself.


Everybody Lies:
House made a half-hearted attempt at attributing John Henry's mental status to low thyroid numbers.

.
People: 

John Henry Giles
Brandy
Tommy
Cora
Dr. Marty Hamilton
Elevator doctor
Chaplain
Process Server
Judge Winter

Incidental terms:
messiah complex
Rubik's complex

Music:
What a Wonderful World - Louis Armstrong

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