Thursday, August 8, 2013

Allowing a Patient to Die - Yes or No?

I was recently invited by KUOW's Katy Sewall to be interviewed about the use of ventilators in the ICU .

In the interview I note two patients.  Both begged to be taken off the ventilator and die.  In one we followed his wishes, in the other we didn't.  In another patient, the family begged to stop; yet in another a family begged to continue.  Death thus becomes a negotiated event in the modern ICU - a real tour de force in applying the ethical principles of autonomy, do-no-harm, and beneficence.

In the back of my mind during the interview was a recent lecture from Coursera (free on line) where they were tying to define death.  It used to be pretty simple - when the heart stops you die.  Well, with new interventions such as hypothermia, a higher percentage of patients are surviving than the current rather dismal 15%.  So they simply stated, that death really is defined by when we stop resuscitation!  I can see from an EMT or ER physician's training that this would be their focus, but the vast majority of us simply have the dwindles from old age sometimes complicated by cancer or heart disease or dementia.  For the frail elderly, CPR rarely works and many patients have standing orders to prevent the terminal assault of chest compressions and electric shocks.

But it's not always straightforward in the ICU in terms of the ventilator.  It's the system support of last resort, bringing oxygen into the lungs and getting rid of CO2.  When everything else is failing we need to talk about the ventilator.  Is it really helping or just prolonging dying?  About 70% of all deaths in the ICU are from withdrawing the ventilator.  Everything else has been tried.  It can be a bumpy road in shared decision making for families and physicians.  Letting go is often the right thing to do, but it's never easy

Thursday, August 1, 2013

Sorry Seems to be the Hardest Word

Elton John had it right, "It's sad, so sad.  Why can't we talk it over. Oh, it seems to me that sorry seems to be the hardest word."

Mistakes are all to common in medicine, but can we say the "hardest word" when we're involved?

Example 1: There's a diagnosis of recurrent lymphoma in the ICU. The oncologist gives a phone order for cytoxan, prednisone, and vincristine. The recorder, working a double shift, mistakenly writes the vincristine daily for 5 days similar to the prednisone order. The fatal dosage is given to the patient over the ensuing days. He dies in bone marrow failure.  The oncologist met with the family and apologized.  A review was carried out.  Systems were improved.  There was no lawsuit.

Example 2:In a radiology department, a cleaning solution rather than a dye is accidentally injected into a patient's femoral artery leading to a painful death.  The hospital representatives and physicians promptly met with the family, admitted a mistake, apologized, and a financial settlement was offered and eventually accepted.

Example 3: A pharmacist fills a prescription for a patient with asthma. Instead of prednisone, the pharmacist mistakenly counts out digoxin, a pill given for heart disease. Digoxin can have severe side effects even at a dosage of one a day. The prescription is followed by the patient: take 8 a day for 3 days, 6 a day for 3 days, etc. The patient calls the MD about the symptoms of severe nausea and notes the pills look different than usual. The medication is stopped and with treatment the patient luckily survives digoxin poisoning.  No apology was forthcoming and the patient lost confidence in the integrity of his providers.

Medical errors frequently hit the headlines. Magazine articles, such as "How the American Health Care System Killed My Father", can be both thought provoking, and provocatively accusatory. Stress and fatigue often play a role.

Medicine is a proud profession, with medical ethics at its core.  But it's complex and fragmented.  Atul Gawande promotes improvements in standards of practice but implementation is difficult.  Medicine is highly regulated in attempts to control quality. Currently doctors, nurses, pharmacists and others can face hospital sanctions, medical disciplinary boards, media scorn, and malpractice threats when they make mistakes. In most situations, a number of things have to go wrong at the same time in order for the mistake to occur. None of the above are my personal mistakes, but "I've been there, done that!"

On a personal level it's humiliating and devastating to be involved in a serious mistake. I sat down with a psychiatrist friend after a significant mistake and it helped to talk it out, but the hospital's legal department had to be notified, affected family members met with, and eventual reports to the state dealt with (and this is in the middle of a 60+ hour week). Fortunately I was not sued, but the worry was palpable.

There's pretty good data now, that fessing up is the best thing to do from a legal standpoint and certainly from the moral view. But believe me, it's not easy when you'd rather hide. When one patient died after a procedure that I probably shouldn't have attempted because he was so sick, I sat down with the family and explained the whole sequence. The son had lots of questions, but then looked reflective and said "It must be hard to be a doctor sometimes. Look it's OK. Dad was going nowhere and he's in a better place now." Basically, he had let me off the hook.

On the prevention side, there's good data from systems engineers (like Toyota and Boeing) that critical mistakes can often be prevented with good quality management and systems surveillance. All hospitals and major clinics have extensive quality control and review. The answers can be simple or complex. For example, for some recent eye surgery I had, I was asked my name and birth date three times by three separate people (even though they all knew me) - along with what operation I was having and on which side. These quality/safety techniques require constant review, updating, and reporting.

There are quality ratings of hospitals by procedures that can be reviewed. The hospital that does large numbers of, for example, carotid surgeries will almost always have better outcomes and fewer mistakes than the hospital that only does a few. It brings into question the future role of the smaller hospitals. The issue is not so much mistakes as the inability to match the experience and quality of an institution that does large number of a complex procedure.

How do we deal with all the parties involved in a mistake (the patient, family, providers, institution, legal, insurer, etc.)? The answer is both simple and difficult - apologize!   Mistakes can be honestly dealt with.  A good example of this are the tort reforms successfully instituted in the state of Michigan. In many states, a doctor's initial discussion with the patient and family about a mistake is not discoverable in a lawsuit.

It is best for all involved to personally make a face to face apology! Sometimes one is forgiven, then sometimes not. But if animosity can be decreased, often a settlement can be reached after an honest admission of a mistake.. Involving the patient and/or loved ones in a case review with all present can be very powerful. It's very hard to stay angry or want to punish someone who can look you in the eye and sincerely apologize, plus actively listening to all your concerns. There comes a point that we all recognize that we're "only human."

The funeral as we know it is becoming a relic — just in time for a death boom

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