The Doctor Is In (And Extremely Annoyed)

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.

19 replies »

  1. There are a lot of assumptions being made by the author about the family’s situation, the woman’s life, etc. — none of which necessarily have any basis in fact.

    – Because of her address, they were automatically “affluent?”
    – Because they wanted to celebrate their mom’s life, not her death, they must’ve been in it for the inheritance?
    – Mom definitely would’ve made a full recovery with no complications had the doctor simply continued doing what he had planned on doing
    – Mom’s amount of pain in the recovery process was of little concern to the doctor, who didn’t even really consider it an issue as to whether she should have the surgery or not (all doctors underestimate pain issues, and wildly underestimate whether it can be properly managed or not)
    – That dialing 911 is equated to wanting all life-saving procedures to be employed (when, for most of us, it is an automatic reaction to needing help)

    Stories can be illustrative and helpful to understand the complications of life and of medical interventions. However, this story just seemed pretty complicated in and of itself, especially due to the apparent assumptions made by the author about the family’s situation and life.

    We can’t know a man until we’ve walked a mile in his shoes. We shouldn’t assume the worst in others just because we disagree with their decisions.

  2. This is a searing experience for an intern. Agree that the pt by calling 911 was asking for medical treatment. Consent for surgery can be presumed with life threatening perforated viscus and no family available. Notion of turning off care afterwards is very troubling. Would opt for family conference with physicians, hospital atty, ethicist and clergy. Then, if care is withdrawn, at least all issues can be aired and weighed.

  3. Seems to me an electronic medical records might have had the patient’s decision to not have life support and all would have been well. The reality is that is not available for most patients.

    Committees are all well and good, but a decision had to be made well within the competence of the attending physician(s).

  4. Interesting story about the flip side of Advance Directives (aggressively enforcing vs. emotionally ignoring).
    I’ve spent the past year researching and writing a website about end-of-life issues (www.deathwise.org). One thing that has become clear is that a signed Advance Directive is often not enough to ensure that your wishes are followed.
    One suggestion is to also write a more detailed explanation of what your wishes are in various situations, and sharing the reasons behind those wishes in writing with family and close friends.

  5. Interesting comments.

    My Mom finally died, at 2 this morning, peacefully in her sleep (she was almost 90). My 15+ years of Next-of-Kin / Caregiver / POA / Legal Guardian (Daughter, Pop, and Mom) are now over.

  6. It is a decision that you must accept the family. Sometimes the pain is no longer supported more and is the reason why the patient says “until that God allows me to live”. This also indicates that the health system is not yet right for millions of people in United States.

  7. Yes. Smartest comment. Much quality of life (end of) improvement would come from this.

    (Sometimes uniformity in healthcare is necessary; the repercussions from wanting to treat each individual uniquely is simply devastating)

  8. What we need is a federal mandate for advance directives and a federally run advance directive database that can be accessed from any computer.

  9. the relatives, and especialy children of a patient will often have emotional reactions. and where emotions are involved you should not seek the logic

  10. One more illustration underscoring the importance of comprehensive advance directives, properly executed and easily accessible. Why such a document is not routinely a part of medical records is an ongoing mystery to me.

    Advance directives — properly executed — should be required by all insurance plans as well as Medicare/Medicaid for beneficiaries. They should expire and be subject to renewal every five years to allow for changes in the person’s health, medical advances or discoveries and changes of opinion (not to mention the passing of designated agents),

  11. No Power of attorney can make a medical decision about a patient, only general decisions and consent. A demand to discontinue support is very different from a wish to not have it started in the first place. Furthermore, a trip to the OR means a period of recovery which is not life support, but post-op recovery.

    When communications are bad and a life is accidentally saved (for the time being) who can really complain.

  12. “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.”

    Loser Pays. Call and Raise.

  13. Seems to summarize what is the problem with health care today. People want autonomy, but yet also want ambivalence and inconsistency when emergent care matters arise. Let’s face it folks, people do not want to die, which at times is completely acceptable per the conditions at hand, and yet at other times, need to accept the facts of life. As long as we as a culture cannot handle when it is time to let go, health care costs will continue to be astronomical.

    Also, the road to hell is paved with good intentions. The motto that belongs over every practicing physician’s doorway. Mine is moreso “no good deed goes unpunished.” That one will be on my tombstone!

  14. I don’t understand how surgery for a perforated ulcer could take 6 hours.