I never said such thing!
“I never said such thing!” shouted the woman with end stage COPD to my consultant when he came to see her in the morning. Just the day before, I spent an hour talking to her and an other hour talking to her family about her decision. She is fed up with her condition and find the treatment we are giving her useless and wants to die. She specifically told me and my colleague that next time her breathing worsens, she does not want to be put on the breathing machine and wants just to be made comfortable.
Its very difficult when a patient refuses a life saving treatment. Doctors have a legal and moral duty of care. Sometimes we are unable to do deliver on that duty because our beloved customers and the final benefactors our hard labor just wont let us. For those circumstances we have an arrangement to shield us from the wrath of lawyers when we allow patients to do something stupid like this. Killing yourself is not a crime. In fact, it was decriminalized in this country in 1961. All We have to demonstrate is that you have the capacity to make that decision. That is not to be confused with euthanasia where someone takes an active action that results in the patients’ death. We are merely making a decision not to force you to have treatment.
It was not my first encounter with this sort of patient but it doesn’t get easier the more you do it. After my long discussions with her, I wrote in her file the 3 sacred lines that will save me from going to prison for the rest of my life when her family turn around and sue the hospital.
“Able to comprehend and retain information.” She clearly remembers everything I told her and was arguing based on the facts I presented.
“Able to believe the information” I was feeling a little more comfortable with my decision seeing how I got to it on paper. I explicitly told her that if she keeps on refusing the NIPPV she is going to die and she believes me and says she is OK with that.
“Able to weight the information provided”. She knows that the NIPPV is the only thing we can do to help as she is on the maximum dose of everything else. She knows the machine is buying her time to fight her way back into her very poor baseline and she does not want that.
And then for an extra layer of protection for me in court and to enforce to myself I was doing the right thing, I added: “patient decision consistent and unchanged over the last two days. If develops Resp Failure II, please offer NIPPU again. If continues to refuse, keep comfortable TLC. d/w SpR. Agrees with the above.”
That is it! I told myself I can put this behind me. I certainly can not force her to have the treatment and my decision to leave her alone is water tight. I will go home tonight and not think of this and I will save my packet of valium for an other day.
It was all fine until the next day when my consultant saw her and tried to talk her out of her decision. She denied ever having said such a stupid thing and even denied talking to me at all. She was either lying or completely not with it for the last two days, in which case I would have encouraged people to leave her alone to die inappropriately.
I went home that day and felt really crap.
PS: This post is dedicated to fashionista for being the most interesting self professed shopaholic I know.
February 27th, 2007 at 10:44 pm
valium again???
February 28th, 2007 at 5:05 am
Your post reminded me of a bit of an incident I had on my last rotation in consequence of which I’ve had to take the stand twice while also fighting off the legal department’s fetish for constantly questioning my decision(s) (as they turn in to the members of the investigating committee and whisper, “What is Clexane, by the way?”). Thankfully now, the nightmare’s almost ended. Still, it had me up many a night; not so much out of fear but more out of guilt because the way I saw it there still must’ve been something more I could do.
On an unusually quiet on-call, as I sat in the doctor’s lounge sometime late in the afternoon pretending to study, I was paged to see a young patient who’d come in with DKA (first presentation). My senior was covering the OPD and as is habitual for interns, I informed him before I headed down to the A/E. Had it been anything else I wouldn’t have been so inclined but DKA being an ICU case the world over (save for Dubai) I decided to fill him in. When I made it to the A/E, I was quite surprised to see a moderately-overweight 27-year-old Filipino gentleman, girlfriend in tow, somewhat drowsy writhing in pain. My clinical suspicion told me otherwise and I decided not to take the emergency officer’s word for it and following a quick history-taking session proceeded to check his lab results on the intranet. His blood sugar was shooting off the charts (1257 mg/dl) with a ketone count of ++ and a sodium of 155 mg. In trying to establish a cause for the precipitation, I ordered an ECG (something that has left me surprised to this day because I thought an ECG was protocol in all cases of suspected acute Diabetic complications considering an MI could’ve caused it or the acute Diabetic complication may be the only symptom of a silent MI in a long standing Diabetic). As I attempted to take a sample for an ABG, my syringe kept trying to suck up blood with a density that matched Vaseline’s. I ordered the nurse to draw up LMW Heparin and start him on half normal saline, considering his sodium. I kept my senior informed the entire time and at the time he seemed to agree. As I began taking down notes and scribbling down orders in the nurse’s station, the emergency officer walked up to me and asked what I was suspecting. I politely said, “Hyperosmolar, non-ketotic Diabetic coma”. And before I could give him my reasons, he began arguing, justifying and patronizing and by the time he was done, it was clear to me that he’d made it personal. “He’s 27″, he said with a rather cynical smirk playing on his lips. I respectfully replied, “It’s rare, but not impossible”. More argument. “But there’s evidence of ketonuria, doctor.” In my most calm and calculated tone, I replied “A ketone count of only two plus with a blood sugar of a thousand plus, highly unlikely. The ketones are because of his dehydration. And the word from all medical literature is unanimous. In clinical practice, DKA and HONK may commonly overlap.” After much thought, he managed a quick “Well, I suggest you get your senior down here right now because obviously you haven’t the slightest idea” before he turned around and walked away. By the time I had shifted the patient up to the ward, the SpR finally decided to show up. After going through my notes, he refused to buy into my regimen and proceeded to rewrite the whole thing. Only this time, he penned down the DKA regimen. Long story short, the patient died (of, what I suspect, cerebral edema or thrombosis) a while after 3:00 AM. Having argued with my SpR in the ward I had decided to take it up directly with the Second On-Call. And although I had made the call, my SpR refused to speak with him blinded by his ego and overconfidence he had lost all sight of the real purpose of him being there. Anyway, a whole lot of politics came into play while the whole thing was being looked into but I believe the family may finally be getting some form of compensation.
On my next on-call though, the emergency officer told me how he’d kept tabs on the case online throughout the night and said he wished to give credit where it was due, apologized and asked me to outline the guidelines for managing a patient with HONK. I did present it on my end of rotation project and a lot was learned that day. I admire that man for having left his ego out while in the hospital, a gear all doctors need to put on. After all, a human life was lost that day only because of it.
February 28th, 2007 at 7:30 am
To all doctors…
…recite Qur’aan every day and pray to his ALMIGHTY to protect you from being put in such nasty positions that will make you wonder the “what if…?” question the rest of your lives…
May ALLAH bless you all!
February 28th, 2007 at 9:49 pm
Stop flirting with fashionista. She’s mine and we’re getting married ok.
February 28th, 2007 at 11:17 pm
lanieres, yeah?
Ash, good to see you around here. I have your website in my RSS reader and I read your blog regularly. Ego is the worst enemy of doctors. One thing I leave at home when I go to hospital is my ego. I admire your standing up to your boss for the sake of your patient. I had similar experiences with other colleagues in the hospital - perhaps I will share them here one day.
CuteUAE. that is what I try to always do :)
The Man In Her Life, she is all yours.
March 3rd, 2007 at 2:35 am
Are you sure she doesn’t have alzheimer’s as well? =P
Maybe she didn’t realize that she was actually going to die until you guys stopped the treatment. Patients usually do not undertake a behaviour unless they know its life threatening and that’s it they have no other chance and they have to do it or else they die.
March 3rd, 2007 at 10:27 am
am back again :p
this story was a bit longer and less exciting than your previous entries .. (just to annoy you sultan :p) it was fair enough =)
wut i actually wanna ask is .. in taking such a consent, shouldn’t there be a psychiatric consult before an internist can agree with the patient in that choice .. (now am sure there is some1 going to be happy about this :p) but really if the consent was taken when she’s really sick she would want to end her misery in the easiest way & for good. I believe that the patient should be in good condition mentally & emotionally to make such a choice and only the psychiatrist can do this (well we can do it also but let’s make their salaries worth a job :p) “kidding- before sum1 start to attack me >.
March 5th, 2007 at 3:48 pm
lol.. as if th daily dose of E.R my friends ake me wtahc everyday wasn’t enough… but i do enjoy ur posts…i have no idea how u can keep up with everything in hospitals… god bless u all…
thank god i didnt get study medicine!!
March 7th, 2007 at 4:10 am
Cute UAE, thanks for the advice, very well said. I say my prayers before setting foot in the hospital but admittedly, I sometimes forget. Those times should account for all my bad days, I gather. But still, alhamdulilah.
Having said that, following the aforementioned incident I began taking comfort in the thought that perhaps all forms of trials and tribulations that come with helping people will only serve to make the reward sweeter, Insha’Allah. Blacker the berry, sweeter the juice, as they say :)
e3ashig, I agree with what you said. Doctors with egos that would put celebrities to shame make for a terribly pitiful sight. I think work ethics take a serious blow in the hands of such caregivers and patient care, a backseat; something that just so happens to be our primary goal.