--- A Case of Knowing When
I read the following article last night, and it reminded me of my own experience which I posted the other day --- the 77-year-old patient of mine who expired while on his way home to Dagupan City. Incidentally, for my foreigner readers who emailed asking where Dagupan City is, you might want to check out this link. Dagupan City is more than 212 kilometers from Manila, and depending on the traffic, you can get there anywhere from 4 to 5 hours by bus or private transportation.
Anyway, the story below is from the New York Times. It was written by Dr. Sandeep Jauhar, who has been writing for the Times since 1998, and one of my favorite medical writers. Dr. Jauhar is a cardiology fellow and medical journalist in New York City.
It seems in parallel universes, there are more and more similar situations happening simulataneously, but with different outcomes. In the case of Mr. Smith here, who is Dr. Jauhar's patient, the positive outcome happened. He overruled the patient and decided instead for the patient who he thought, along with his other colleagues who knew the case, was not thinking clearly.
On a Matter of Life or Death, a Patient Is Overruled By SANDEEP JAUHAR, MD
From the New York Times
October 5, 2004
Mr. Smith could not breathe. Bright-red blood, filling up the air spaces in his lungs, was spewing from his mouth whenever he coughed.
"So what are you waiting for?" I asked the cardiology fellow on the phone, trying to rub the sleep out of my eyes. "Intubate him."
"He says he doesn't want a breathing tube," the fellow replied.
"He's going to die without it," I hollered.
"I know," the fellow said matter-of-factly. "And I think he knows, too. But he still doesn't want it."
I sank onto my living room sofa. What to do? Mr. Smith had come so far since his heart attack. Cardiac catheterization. A drug-coated stent to open up a blocked coronary artery. Intravenous blood thinners to keep the stent from clotting. Was it going to end like this?
"This is a reversible complication," I told the fellow. I had seen it before with aggressive blood thinning.
With a few days of ventilatory support, the bleeding should stop, we would be able to pull out the tube, and he would walk out of the hospital.
"What do you want me to do?" the fellow replied. "He's refusing."
He said that he had already tried the usual measures short of intubation: supplemental oxygen, diuretics, a pressurized face mask.
"Do you think he has decision-making capacity?" I asked. If not, we could make the decision for him.
"I think so," the fellow replied, his voice thick from lack of sleep. "He apparently told the residents several days ago that he never wanted to be intubated."
"He can't do this to himself," I said. "Try to talk to him again. I'm coming in."
Outside, the sun was rising. Speeding to the hospital on a lonely stretch of freeway, I mulled over the options. As far as I could tell, there were only two:
From my car, I called the cardiologist who had performed the catheterization. "Intubate him," he said immediately. I explained that Mr. Smith did not want a breathing tube. "Who cares?" he cried. "He's going to die! He's not thinking straight."
- we could continue the current treatments and watch him die,
- Or we could intubate him against his wishes.
Perhaps he's right, I thought. After all, who in his right mind wants to die? Were we not asking too much of Mr. Smith? Patients have a hard time properly weighing their options under the best of circumstances. In an emergency like this, how could we expect him to make the right choice?
As an experienced doctor, wasn't I in a better position to make Mr. Smith's decision than Mr. Smith?
When I got to the cardiac care unit, a crowd of doctors and nurses was at the patient'ss bedside and an anesthesiologist was preparing to insert a breathing tube. The cardiologist I had just spoken with took me aside. "He's breathing at 40 times a minute and his oxygen saturation is dropping, so I made the decision to intubate him."
I nodded quietly. I had made the same decision in the car.
Once the breathing tube was in, blood started rising in it like a red column. Nurses had to scramble for face shields and yellow gowns to protect themselves from the red spray. Pretty soon, someone was pouring brown antiseptic soap onto Mr. Smith's groin in preparation for a central intravenous line. As needles started piercing his skin, Mr. Smith started swinging wildly. In intensive care units, the steamroller of technology starts moving quickly, flattening all ambivalence.
Eventually, with sedation, Mr. Smith settled down, and the critical care unit staff settled in for a long period of observation. If we had gambled right, he would recover within a few days. "If you get through this," I whispered to Mr. Smith, "I hope you can forgive me."
I have never been able to balance satisfactorily in my own mind the twin pillars of modern medical ethics:
As a doctor, when do you let your patient make a bad decision? When, if ever, do you draw the line? What if a decision could cost your patient's life? How hard do you push him to change his mind? At the same time, it is his life.
- patient autonomy, and
- the physician's obligation to do the best for his patient.
Who are you to tell him how to live it?
Mr. Smith had an unusually rocky hospital course. The bleeding in his lungs continued for several days, requiring large blood transfusions, but it eventually stopped. His blood pressure was too low, then too high. He had protracted, unexplained fevers.
After a few days, I ended my service as the attending physician in the critical care unit. A week later, I heard that Mr. Smith's condition had improved. A week after that, a fellow stopped me in the hall to tell me that the breathing tube was out.
When I went to see him, I realized that I had never really looked at him as a person. He was a tall, muscular man in late middle age, with a broad forehead, a flat nose and high, handsome cheekbones. I went to his bedside and introduced myself. He didn't recognize me.
"When you were really sick, I was one of the doctors who made the decision to put in the breathing tube," I said. He nodded, eyeing me curiously. "I know you didn't want the tube," I went on, "but if we didn't put it in, you would have died."
He nodded again. "I've been through a lot," he finally said, his voice still hoarse from two weeks of intubation.
"I know," I replied.
"But thank you," he said.
In my case, I let the patient and his relatives decide what is best for them, after I have explained all the risks that went along with the decision they made. I was against their decision to leave the hospital, but they preferred leaving anyway.
So, there it is, dear readers, two sides of the same coin.
I hope and pray the next time a similar case happens, I get to have the positive outcome.
But who knows? As Dr. Jauhar observed, it is really difficult to balance between patient autonomy and physician obligation.