Sunday, March 16, 2014

Non WoW: Choosing between humanity and the correct clinical decision

I was faced with a difficult decision this weekend.  It started even BEFORE the weekend.

On Friday, I had a phone call from a colleague about a patient that had been deemed not suitable for anaesthetic by various other anaesthetists on the days the operation was scheduled.  The orthopaedic surgeons wanted it to be done on Sunday - sneaky buggers, think they can put the worst cases on the weekend where they think nobody will notice? HA! - because the consultant was available that day to have the procedure done.  My colleague was outraged about this patient and the gall of surgeons not to be able to do the right thing and allow the patient to pass away peacefully.

The patient was a 75 year old lady who had lung cancer diagnosed 2 years ago, and it had already metastasized to her brain and her bones.  She suffered confusion because of the swelling in the brain from the cancers that had spread to there, and she was old and frail, and she had a broken hip from a fall, and she had actually fractured through a cancer that had eaten away and weakened the bone in her leg.  She had a history of clots in the legs that spread to her lungs causing embolisms and had been on blood thinners to prevent that (and having cancer, she was at even higher risk of having that happen again). She had a poor prognosis and was at high risk of morbidity or mortality even if we didn't do an operation to fix her hip - which was mostly for analgesia/pain relief, so that the patient could go home.  She probably would not be able to walk as she also had a fracture through her pelvis which we could not fix (also through a cancer spot that had eaten the bones of her pelvis).

I said that I would go see the patient for myself, but I agreed with my colleague and the others who had rung me afterwards.  This was a very poor candidate for surgery.  She was not fit for surgery by the sounds of it, and to do so would be folly.  A demented/confused elderly lady would benefit more from palliative good analgesia for her pain from her broken leg, and be allowed to pass away from her injuries than be subjected to an operation that would not bring her any benefit.  The orthopaedic surgeons love getting their hands on people and doing operations (all surgeons for that matter) with little thought on what happens in the post operative period - such as whether the patient suffers a stroke, a life threatening pneumonia or blood clot which can severely incapacitate a patient beyond all hope of recovery - but to them the operation itself was a success.  Every now and then I have to talk a patient out of an operation because nobody ever tells them what happens after the operation - and how much pain and suffering they will go through for no great benefit, and not even a chance at a cure.

So off I went to see the patient, to let them and everyone know that this operation was not to their benefit and my recommendation was to allow the patient to be palliated at home with her family in attendance.

What I did not expect to see was a wizened little old lady sitting up in bed, looking very alert and talking to her family.  Her grandson's wife, and her grandson's wife's mother were in attendance and they looked at me expectantly as I introduced myself to the patient and her family.

This lady was different to how I was described.  The orthopaedic registrar (training surgeon) had told me earlier in the day that she was looking a lot better from the end of the bed, and for once, they were right. She was sharp, had insight and asked intelligent questions, and I told her and her family that I was here to decide whether or not we could proceed to have an operation on Sunday.  Her vitals were stable, and yes she had dreadful disease and would highly likely have a poor outcome, with a high possibility of an intraoperative adverse event as well she was so frail.  Her family said that all they wanted to do was to have her operation and go home. They had been told that if she didn't have her operation she would have to go to a nursing home, because she would need full time care especially in regards to having a morphine infusion for pain relief, as it was too dangerous to have her family do it without full nursing care.  Her daughter, who was actually a nurse, was determined, as it was her mother's wish not to die in a nursing home, but to die at home, surrounded by the family that she loved.

I had tears pricking my eyes as I considered what I was going to do.  What if this was my own mother? I would wish that the doctors looking after her would respect my wishes and allow her to go home to die - and if she needed an operation for that to happen, then I would hope that someone would overlook the risks of the operation and go ahead with it if it was at all possible.  I would accept the high risks of the surgery and not blame the anaesthetist or any of the staff for any adverse outcomes because I would be so grateful that they had evern tried to do it - and even if my parent died under anaesthetic, they would have died in peace and not in pain, and that is not a bad way to die, as long as you had said all your goodbyes already.

Professionally though, I was conflicted. Doing a patient who was at high risk of dying under the procedure (or worse, becoming a vegetable) due mainly to the decision to proceed with anaesthesia made me look like a clinician with bad judgement. If she died under anaesthesia (or within 24 hours of anaesthesia), I would have coroner's forms to fill, and an investigation would have to take place. If the family did a complete turnaround and said that I was negligent for having her die under my care and then sue my ass to hell and back, ruining my career and reputation, then I would have a REALLY big problem - my life and career would be over. What they wanted was not an easy decision to make and it was no wonder NO anaesthetist was willing to take the risk and perform the operation - she had been cancelled twice already because the anaesthetists said she was not fit, just based on her illness alone. But they had made the soft cock judgement and said she was not fit for that day, and made it someone else's problem, rather than go and document in the notes that she was not to fit for anaesthesia PERIOD.  And now, the problem had come to ME. I had made up my mind before I had gone upstairs to document in the notes and take the responsibility and say that she was not to have the operation EVER as she would never be fit for anaesthetic... and yet now, here I am standing there, and it wasn't what I had planned to do at all because the picture was a little different to what I had been told.

So I went and rang the daughter, the main carer of the patient, and spoke to her about my thoughts. I said to her, that I am sure she knew that this operation was risky, and that nobody wanted to do it because of the fear something bad would happen.  She told me that she and her family accepted those risks and were happy to proceed.  I told her that even though it's easy for them to accept those risks, it is not easy for any doctor to let any patient die or have a bad outcome after entering their care - that it was stressful to have someone die, and that it was a risk to our reputation and career if it was perceived we were doing the wrong thing by going ahead in the first place.  So I said that my decision was to go ahead with the procedure despite all those risks, because if it had been my mother or grandmother, I would only wish that someone would go ahead and do the anaesthetic because it was the humane thing to do, for the chance at being allowed to go home and die with dignity, not die in a strange nursing home, or in the middle of the night all alone in the hospital.  I also told the daughter that I would really appreciate it if she did not blame me if I chose not to do CPR for her mother if she had a cardiac arrest during the procedure (though I would do all possible medically not to let that happen) as it would allow her to die in peace without suffering.  What I was trying to say, but not sure how to say, was that I was trusting her to accept the risks and not turn around later and persecute me for anything that went wrong during the operation, because even though I had told her the risks, it is never nice when it actually happens and then people are looking for someone to blame.  She cried and thanked me profusely for doing the operation, for giving her mother the chance to go home.

Thank god it was over the phone, so nobody could see the tears that had welled in my eyes as I spoke to her.

My registrars were shocked - they thought I was crazy. The incharge nurse in theatres shook his head at me and said "Well, I will go get those coroner's forms for you now then," and the scrub sisters were a little surprised but when I explained to them my reasoning, they accepted my decision.  I have thought about how best to do this procedure given the cancers in her brain make her very prone to waking up very slowly from anaesthesia or even not waking up at all, and hoped I could get away with an epidural/regional anaesthesia technique - but with her blood count being a bit low, that had its risks too.  Ugh decisions!

But whatever the outcome, I have decided to myself that I think this is the right choice.  My colleagues may have a lot to say about it, but I have chose the humanity side over the medically correct side.  And I wish that the two would align - but every now and then it doesn't and you can't blame someone for the choices they make, because there are always two sides to a story. I can only hope that people realise doctors are human too - and the choices we make affect us, and our futures, as much as they affect you the patient as well.

8 comments:

  1. Good for you.
    I work in a totally different field but when I first started, someone who I respect said to me, "always do what you feel is morally right, regardless of whether it's what management/policy dictates". I've had a few decisions questioned since then but I fight 100 percent for the people I'm meant to advocate for and at the end of the day, that's all you can do.*
    I hope everything goes ok.

    *I might not work in medicine but my actions could have massively negative effects on people's lives. In fact colleagues have been blamed for more than one suicide.

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    1. Thanks Erinys. If she pulls through I will feel good. If she doesn't - well that's where the conscience wrestling will be twisting through my guts.

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    2. And it's never easy, making decisions that affect people's lives. Thank you for your understanding <3

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  2. I would hope that if I ever have to face a similar situation I am as fortunate to have a caregiver like you. I'll be praying for good results.

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  3. Whatever the outcome, re-read this post. It's very powerful, Navimie--your honesty in your struggle, and of what you can and cannot control humbles all of us.

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  4. Like Jeni said, if I ever had to leave my life in someone's hands it would be yours. I would be happy with your decision live or dead. Because if I were in her shoes dying would be the second best outcome after a successful operation. The nursing home option, dead last.

    I hope the outcome is one that's good for you both.

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  5. I had a person I was responsible for (in a manner of speaking) develop an neck artery that ballooned. I can't remember the name of that. Anyway, he was told that if he didn't have the operation there was a 100% chance he would die. Also, there was a 90% chance he would die on the table if he did have the operation.

    What a choice!

    He decided to do it, and his family was leaving.

    Let's call him Bob. I said, "Bob, you've got a unique opportunity here."
    He said, "How so?"
    I said, "Everyone knows that there is a great chance you're about to die, right?"
    He said, "Yes."
    I said, "Well, you've got an opportunity to tell your family exactly how you feel about them, what you may want them to do, or just about anything that would be a 'last words' kind of thing. The very last words you speak to them can be words of blessing."
    He said, "You know, you're right! Let's call them back in one at a time so I can bless them."

    And, he did just that. He blessed every member of his family. Told them how much he loved them, and how he appreciated each one. He even blessed a young lady set to marry one of his grand kids. He got her to promise to finish college, even if she did get married!

    All that to say, if we come to a time of possible imminent death; and the person is lucid. We actually hold a very powerful and significant moment in our hands. We hold something holy.

    Z

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  6. What was the outcome?

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