My friend Tom's father-in-law, Frank, was admitted to a hospital a few years ago after suffering a massive stroke from a cerebral hemorrhage. Frank was elderly and already in poor health before suffering the stroke. The blood clot in his brain was quite large and, no matter what course of treatment was selected - medical or surgical - Frank was not expected to fully recover and his already frail health was likely to deteriorate.
Frank was unconsciousness by the time he arrived at the hospital, so it was up to his wife and family to decide how to proceed. Given his very poor prognosis, the family started thinking about Frank's attitudes about life support. They knew that he unequivocally believed that a life hooked up to machines was not a life worth living - and so began their consideration of foregoing surgical intervention and adding a "do-not-resuscitate" (DNR) order to his chart.
But their deliberation was a short one.
All discussion ended when Frank's surgeon simply announced that the plan was to move ahead with surgery. His stated reason: "I am in the business of saving people's lives, not killing them." Since Frank's vulnerable and conflicted family really didn't think they were in the killing business either, they agreed to a highly aggressive course of treatment. Frank survived the procedure and lived another year - bed-ridden and never fully regaining consciousness.
Ed's family takes full responsibility for making treatment decisions they ater came to regret. Still, they have never been quite comfortable that they made the right choices. They don't blame the doctor for 'forcing' them to do anything, but do wonder what they would have decided had he not been so certain about how to proceed.
Is it a problem when a physician equates a choice not to agressively treat a patient with killing that patient? Did the balance between Ed's values (as understood by his family) and his doctor's judgment tip in favor of the doctor's biases? If patient and families can be willingly coerced in a crisis, is patient "choice" more of an illusion than a reality?
PJM
2 comments:
Thank you PM and allow me to reply to your comment with my 20 plus years in nursing and most recently in hospice.
For whatever reason people who are not doctors or nurses still have an unusual amount of respect for their physicians. This crosses all cultures and some most certainly more so than others. Patients and families a stressful healthcare situation will always look to their physician for guidance. I have only met a few doctors who had an unusual degree of passion for providing their patience with fruitless treatments. I suspect that since the 1970s that this has become more so because of the ease of the insurance reimbursement for major surgeries. One would think twice about forking out $100K for old granny.
Another issue at play behind the scenes in your friend situation was that the hospital administration certainly felt that the family was not making a decision fast enough. Fast enough meaning within their DRG allotted length of stay. They pressured the hospital doctors and nurses and the surgeon took the path of least resistance and pushed for the surgery. By doing the surgery the hospital got an additional DRG and an increased length of stay which equals more money. Unfortunately your friend lived another year possibly as a result of the surgery.
At any time of when a patient is incapacitated whether or not the DNR or power-of-attorney paper works are in order, if a family member is extremely vocal in their disagreement, the hospital will pull back and send in the social workers to try and massaged the situation along. A hospital and never wants to be in a position to defend a DNR statement which is a very weak legal document.
I had a large and clearer tatto on my arm which states DNR and DONOR. Although this is extremely nonbinding, I am hopeful that if I am brought into the emergency room, the doctors and nurses will indeed know my wishes. Upon seeing this tag to I am certain they will just move a little more slowly.
Perhaps I am not fully understanding the question posed, but I am failing to recognize the conflict in the situation. Frank's diagnosis at entry to the hospital was one which hypothesized that he would not fully recover. However, it was not a prognosis where he would never resume conscious or coherency (unless I am mistaken?) Therefore, the physician's decision in saving his life would appear to me to be a matter of course. Just because he was not able to resume complete function of all his previous abilities does not mean his life should not be saved.
I am distinguishing this situation completely from the other side of the spectrum, where the patient is diagnosed as having to remain forever dependent on machines for all living purposes (breathing, heart beat, etc.). In that case, it is up to the family and the patient's prior expressed wishes whether or not to impose a DNR order on their medical treatment, as the patient themselves would never be able to have the ability to express their wishes otherwise. However, in the current situation, it would appear that merely because Frank was unconscious when he was brought in does not indicate that he would forever remain in that condition. The fact that his prognosis was "poor" does not mean that it was an almost certainty that he would never wake up. The fact that he never regained consciousness was an unfortunate unforeseen occurence.
When someone's life is still capacable of being saved, and especially under time pressures, I feel that it is not only the right, but rather the duty, of the physician to make that judgment call. They are the ones with the medical training and expertise to determine how likely the chances of saving the patient are.
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