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Demystifying Medicine One Month at a Time

A Story of End of Life Care in America (Cont.)

The next morning I came in to round. The patient’s name was still on our list.

We went to her room. She wasn’t there. But the bed was missing, too.

After the fact.

After the fact.

“Did the patient in 1214 get transferred to hospice?” I asked to no one in particular outside her room.

“She’s in the OR,” said the ward clerk.

What the fuck?

I was furious. A patient whose dying wish was to be made comfortable, at 94 with dementia, severe weight loss, who’d never walk again, had been “taken” to the operating room, possibly against her family’s wish to have her broken hip “pinned?”

How had this decision been made? Who’d made it? And why the fuck had nobody talked to me about it? As the attending physician, I was legally and ethically responsible for the care of the patient.

I called the OR. I got the surgeon on the phone. “This patient had an advance directive. Her son, who’s her power of attorney, wanted her to go to hospice. What’s she doing in the OR?”

“I’m just covering my colleague,” came the reply. “He consented her. I’m just going to ‘pin’ her hip, not repair or replace it. Please clarify this with the family and let me know what they want to do–as soon as you can–she’s already on the table and the spinal’s been administered.”

Great. The train had not only left the station, it was already hurtling down the tracks. I did not appreciate the ‘covering’ surgeon’s passivity. He was just doing what he’d been told. Hey, fella-how about taking some responsibility to clarify and verify things before cutting on anyone? Did it strike you as weird to take an emaciated, demented 94 year-old to the operating room?

Apparently not. Not at all. I remembered the nurse practitioner’s bizarre comment from the day before: “We’ve only not operated on a broken hip twice.” Is that because those patients were already dead?

I found the family in the surgical waiting area. Oddly, it was the patient’s other two daughters, not the power-of-attorney son and nurse daughter with whom I’d spoken the day before.

“Did you and your siblings consent to this procedure?” I asked them. “Yesterday your brother and sister told me that they wanted no further intervention–they wanted your mother to go to hospice to live out her remaining days in comfort.”

“Well, yes,” one of the daughters told me. “They told us it’s a minor operation and will just ‘stabilize’ things before she goes to hospice. They warned us that she’d be in pain any time she moved, and we didn’t want that. Isn’t this the right thing to do?”

With all my soul I wanted to scream at her, “Let your poor mother die! Why on earth would you subject her to this ridiculous ‘operation’ and spinal anesthesia? And what the fuck kind of surgeon comes by after the decision has been made and brainwashes a poor family into an unnecessary operation and doesn’t have the courtesy to discuss the ‘plan’ with the attending physician?”

But I didn’t say that.

She needed my support. “Well, this is among the most difficult situation anyone ever faces,” I said. “There’s no right answer. For some people, NOT doing surgery would be the right decision. For others, a sense of fixing what’s broken will seem like the right course of action.”

I asked the two sisters if their brother and other sister had agreed with this. I was surprised that they weren’t there at the scene. Perhaps the power-of-attorney brother who’d made a resolute decision a day earlier based on what his mother would have wanted had changed his mind. Perhaps he’d felt guilty disagreeing with his sisters, and wanted consensus above all else. Perhaps it really was a ‘minor’ procedure and the right course of action to mitigate the mother’s suffering.

But I’d seen her in her bed. She’d smiled at me. She’d discussed having tea. She wasn’t writhing uncomfortably or looking in distress.

I was angry. Had the consenting surgeon simply seen dollar signs? No broken hip goes unfixed? He’s a hammer and the patient was a nail?

Let me take the high road: Maybe he genuinely believed that pinning the patient’s hip would improve her quality of life in the days she had left. Maybe he had some evidence I’m unaware of that pinning hips in demented 94 year-old patients is the most efficacious plan of action. All bow down before the Gods of Evidence.

But he should have spoken with me. As a colleague. As a professional. As the one responsible for the patient’s care. Maybe he could have persuaded me that this was the right thing to do. Maybe he’d have even turned the tables and shown me that I was the one being inhumane. After all, how ‘right’ is it to send a feeble old woman to die with a broken hip?

Too bad for all involved here that his thought process was not made transparent. He and I will clearly be having a conversation, likely with hospital administration in attendance, about what happened here. This is a conversation we should ALL be having.

3 Comments

  1. This is such a gut-twisting scenario, I can’t help but cringe as I read it. It’s something none of us wants to face with our own families. And that business-as-usual medicine is beyond frustrating — infuriating for both professionals involved and the families as well. Nice post.

  2. Wayne T. Johnson

    January 1, 2013 at 11:57 am

    “As the attending physician, I was legally and ethically responsible for the care of the patient.

    “I called the OR. I got the surgeon on the phone. “This patient had an advance directive. Her son, who’s her power of attorney, wanted her to go to hospice.”

    I think this highlights the difficulty presented by the fact that someone who has no medical qualifications but to whom the mother (who may have no qualifications to make a medical judgement) has conveyed power of attorney (a l e g a l concept) can override the judgement of someone (1) qualified to make a medical judgement and (2) to whom the patient, by previously consulting the physician, has arguably conveyed her trust prior to any medical crisis. At some point in this episode, the woman’s body almost becomes a third party to the debate. WTJ

  3. Wayne T. Johnson

    January 1, 2013 at 12:01 pm

    son, who’s her power of attorney, wanted her to go to hospice.”

    I think this highlights the difficulty presented by the fact that someone who has no medical qualifications but to whom the mother (who may have no qualifications to make a medical judgement) has conveyed power of attorney (a l e g a l concept) can override the judgement of someone (1) qualified to make a medical judgement and (2) to whom the patient, by previously consulting the physician, has arguably conveyed her trust prior to any medical crisis. At some point in this episode, the woman’s body almost becomes a third party to the debate. WTJ

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