On a Saturday around noon, an 85-year-old woman was brought by ambulance to the Emergency Department with severe abdominal pain. She was confused and unable to provide any medical information. Her X-rays showed marked accumulation of abnormal air in her abdomen, a dreaded sign of a perforation in the intestinal tract. Her blood pressure was quite low, requiring treatment with intravenous medications. As the general surgery intern on call, I was asked to see her.
A physical examination showed her abdomen was rigid and extremely tender, which confirmed this was a surgical emergency. Laboratory testing indicated a serious infection, likely the result of intestinal contents leaking into the abdomen, as well as mild kidney injury. Multiple efforts to reach either family or friends by telephone were unsuccessful, and a conservator or someone with durable power of attorney could not be identified to provide informed consent. The patient clearly needed surgical intervention, so two surgeons wrote notes documenting the need to bring her immediately to the operating room as this was a “life-threatening emergency situation.”
During a 6 hour procedure in the operating room, she underwent repair of a benign perforated ulcer in her stomach. She was brought to the recovery room with the breathing tube in place only because it was late in the evening, with the plan to remove the breathing tube promptly in the morning. I saw her during a post-operative check around 9pm, and all seemed to be improving. She was now requiring much lower doses of medications to maintain an adequate blood pressure, and her kidneys were recovering with a good urine output.
About an hour later, I was notified by the nurses that the patient’s children had arrived. They demanded immediate withdrawal of support. One produced paperwork indicating that she was her mother’s durable power of attorney. She stated that her mother would never have wanted to be “on life support, intubated, and in need of dialysis or blood pressure medications to artificially maintain her blood pressure”.
I explained that the intubation was only prophylactic, her kidneys were recovering, dialysis was unlikely to be needed, and the blood pressure medications could soon be discontinued. However, I was told that the patient would never have consented for surgery initially, if she had known of the difficult and long road to recovery ahead. One of the other children stated that he was an attorney and began reciting the legal responsibilities of the healthcare team to respect the wishes of both the patient and the durable power of attorney.
I telephoned the attending surgeon, who was completely dismayed. It was now early Sunday morning and involving either the courts or convening an ethics committee seemed unlikely. I was instructed by my attending to honor the family’s request, and to discontinue both the blood pressure medications and the mechanical ventilation. I followed these directions, and the patient died shortly afterwards.
As I completed the death certificate, I noted that the patient was widowed, and lived in a very affluent area of San Francisco. As I stopped by the bedside, I saw that the children were sharing a bottle of wine, which they termed “a celebration of their mother’s life and memory”. They invited me to enjoy a glass with them, but I politely declined. As I left the ICU, I felt discomfited by what I felt was the family’s inappropriate reaction. In the intervening years, I have often wondered whether the children may have been unduly motivated by the conflict of interest of a potential inheritance.
This event happened during the second month of my internship, and I recognize now that when the healthcare team was threatened, we backed down to avoid angering the family. Seventeen years later, in retrospect, I would have done three things differently. First, as this sudden event must have been traumatizing, I would have encouraged the family to seek the services of a grief counselor before making the final decision to withdraw support. Second, I would have contacted the hospital leadership, and attempted to assemble an immediate ethics committee meeting. Third, I would have been a stronger advocate for my patient. What remains most disturbing to me is that she was brought to the emergency room after calling 911 herself. She had progressed to delirium during the time she was transported by ambulance, and by the time she arrived, was unable to state further her own wishes. But the intent of her actions was clear. She at least wanted medical attention.
My patient’s story illustrates the need for a better system to determine whether a durable power has been designated, though even that may prove insufficient if the decision maker cannot be reached in a timely manner or has a conflict of interest. Doctors more often struggle with the opposite scenario, of a family that insists on continuing clearly futile treatments when imminent death is certain. In the final analysis, expensive and precious healthcare resources were pointlessly expended in the last 12 hours of my patient’s life. If we regard healthcare as a public good, then the best interests of society should be weighed through the perspectives of multiple stakeholders before making decisions with irreversible consequences.
Dr. John Maa is an assistant professor of surgery at UCSF. He focuses on improving the quality and access of emergency surgical care.