Saturday, March 20, 2010

Pull the Plug - Now!

The voice on the phone is demanding, quavering, pleading; "Dr. deMaine you are going to be the attending Critical Care doctor when our mother is transferred to your hospital today. She needs to be taken off the respirator and allowed to die. We have been pleading with the doctors at the burn center, but they keep doing more procedures. We want her off life support as soon as she gets there."

I am a bit taken aback since I'd never heard of the patient, let alone that I am destined to be her doctor in the ICU. I tell the family to try to come to the hospital to meet with us today when the patient arrives.

After hanging up the phone, I receive the call from the transfer coordinator, "We have a patient in the burn unit who is 87 years old. She has 50% third degree burns and 20% second degree burns. There have been multiple grafts. The complications have been pneumonia, stroke, heart failure and adult respiratory distress syndrome. The house staff will fill you in. They think she should stay there but the family is very unhappy that the patient is suffering through all these treatments."

In thinking about this, I first reflect that it's not too uncommon that the family feels left out in critical care decision making. They sometimes don't understand that a sick relative may look awful, but still have a good chance of recovering. Lots of communication is needed, but the doctors often don't have the best skills in this area. It can be very hard to switch from a "curative mindset" to a "palliative mindset" for all involved.

I'm paged to the ICU when she arrives by a life-support transfer Medic One team. This unfortunate woman has now been on life support for one month. There are multiple burn grafts in place. She is unresponsive to verbal or physical stimulus. The blood pressure is marginal, kidney function poor, liver functions elevated, and chest x-ray diffusely abnormal. If this were a young patient, there might be some hope but this woman is going progressively downhill. It's a tough call. If the patient could talk to us, what would she want?

I meet with the family, the new RN team, and our social worker in the conference room. After introductions, I give them an outline of the process we'll use over the next half hour to go over their Mom's care. First we review all the medical facts and time-line of hospital care so far. Then I outline the options for further care including discontinuing care - and the benefits and burdens of each possibility. We discuss her daily life prior to the the fire. Her son and daughter, Jerome and Ada, describe her as a happy person yet very limited over the past few years due to arthritis. She was feeling isolated because all her contemporaries had died.

We then discuss her wishes for aggressive life support care. She has never signed a living will or executed a durable power of attorney for health care. Her husband is deceased, so under Washington State Law, the decision making authority rests with her two adult children who must agree. Both are adamant that Mom would never have wanted this kind of aggressive care. She has been ready to "pass on" for some time.

Jerome says, "It's bad enough to die once in a fire, but dying every day in the ICU is just too much!"

After nearly an hour of discussion, which includes the nurses and social worker, all agree that the most reasonable course of action is to remove the ventilator. I ask the family to step out of the room. Then I turn off the monitors in the patient's room, make sure the patient is still unconscious, turn off the ventilator and remove the endotracheal tube.

Jerome and Ada are at the bedside holding mom's hands as she exits from this world. There are tears of both sadness and joy. The nurses and social worker continue to be supportive and help the family with the arrangements that need to be made.

Comment: About 70% of all deaths in American ICU's occur by removing life support. Heroic attempts have been tried, but ultimately failed. Medicine is slowly facing the issue of futile and expensive care at the end of life - a time when patients, families and medical care givers often prolong care far beyond a reasonable limit.

The day after the patient's death, I got a call from the surgical resident in the burn unit, wanting to know about the patient's grafts and general status. I explained as gently as I could that we removed life support at the request of the family. The surgical resident wasn't happy.

Here's my encouragement with patients and families to help prevent confusion at the end:

1. Write your wishes down and share them with your loved ones and doctor. Execute a Living Will.
2. Appoint a trusted person who knows your heart as your Durable Power of Attorney for Health Care. Have it notarized.
3. Ask your state medical association about a physician who specializes in palliative care or in geriatrics.
4. If that is unsuccessful, contact Compassion and Choices for help in choosing a sympathetic doctor in your state at http://www.compassionandchoices.org/
5. Ask your state medical association if your state has a POLST form. This stands for Physicians Orders for Life Sustaining Treatment. It respects your wishes and is signed by both you and your doctor. The availability of this form varies state by state.

Sunday, March 7, 2010

The Unasked Question

A large heavy package arrives at my office. I am expecting these charts after my conversation with the attorney. He says, "Doctor deMaine I'm representing a prestigious teaching hospital related to the death of a firefighter." He briefly explains the issues involved and I agree to review the case.

The large cardboard box contains hundreds of xeroxed pages from treating doctors outside the hospital as well as the complete hospital records and the autopsy report. I lug all this home and spend hours that evening sifting and sorting the time-line of events. This 34 year old female fire fighter begins to notice being easily winded with exercise over the past few months. She sees her internist who checks her heart and lungs including a chest x-ray and EKG. Her heart rate is 90 which is within a normal range but higher than her usual rate of 70. This isn't enough to raise red flags at this point, but there's no diagnosis for her symptoms.

Subsequently, at a house fire, she needs to scale a ladder carrying a hose. Becoming very winded, she collapses and has a brief "seizure-like" episode. Medic 1 responds and she is taken to the hospital where she is evaluated in the Emergency Room. Her blood pressure is fine, the heart rate is 110, and the neurological exam is normal. The neurology service admits her for observation and a "seizure workup".

After two days in the hospital, no diagnosis is established. The shortness of breath history is noted. The pulse rate never drops below 110. She is discharged from the hospital with an appointment made for the Pulmonary Clinic in two weeks. Three days later, she collapses in the shower. Her roommate calls 911 and she's brought to the hospital where the diagnosis of a pulmonary embolus is established. She has sudden cardiac arrest in the x-ray department and dies undergoing CPR.

I notice from her outpatient record buried in her history that she has been taking birth control pills for the past six months. Also there is no history of asthma, allergies, or any lung disease.

The attorney is not happy when I tell him that I can't testify for the defense. "Settle this one and try to stay away from a jury", is the best advice I can give him. "Look," I said, "if you framed the case with the appropriate information, any emergency physician would come to the diagnosis. You have a young woman on birth control pills who is becoming short of breath. This is a red flag for blood clots beginning to clog up the lungs. They start in the upper legs and pelvis and have no local symptoms - but can be deadly as they break loose and are pumped through the right side of the heart into the arteries of the lung. The heart rate goes up and I'll bet you anything that her neck veins were distended (from the obstructed blood flow). The 'seizure' was a red herring. The patient shouldn't have been discharged without a diagnosis. Basically no one put two and two together. The right questions weren't asked, so the right diagnosis was never considered. A simple lung scan would have made the diagnosis and anti-coagulation would have saved her life."

The attorney angrily told me that I wasn't being helpful to the medical profession and that I was prohibited in testifying for the plaintiff (which I very much dislike to do anyway).

Comment: This was a very sad death and very preventable if only the diagnosis of pulmonary embolism had been considered. There aren't many things that cause a young woman on birth control pills to have severe shortness of breath, but this patient was felt to have a brief "seizure" and admitted to the neurology service. Each specialty tends to focus in its area and we naturally try to fit the patient into a learned pattern. The smartest doctors I know (please count me out) have a sixth sense in a case like this; an ability to step back and ask the right questions.

All this said, I don't think the doctors sued were bad. Dragging them through the courts when they all felt guilty and terrible doesn't help anyone. I hope that in tort reform that we can develop expert review panels who can review a case like this, bring about a fair settlement, and not clog up the legal system for years with expensive "expert witnesses", discovery, rulings, appeals, etc.

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