Monday, May 5, 2008


In the comments section of my last post my mom brought up the very good point of view that the patient's or the patient's family's wishes are the deciding factor in this case. And in fact, in this particular case it WAS the patient's wish to 'try everything' which prompted the cascade of events that ensued. However, I think we as a medical community and as a society err on the side of intervention. It is a fine line we traverse between what is beneficial and what is torturously unbeneficial for the individual being treated. The question with a conscious patient who is able to consent, in my mind, is 100% informed consent. Simply posing the question, "Do you want us to do everything possible to save your life?" is not enough. Medical advice, particularly from a physician, is weighed pretty heavily by people seeking their care. Implicit in the question above is the preference for intervention versus letting nature take its course and offering comfort measures to the person involved. In other words, if a physician truly presents the options in as unbiased a way as possible, an individual who may have chosen to 'try everything' if posed the above question (or simply gone along with the physician choice to intervene without actually asking for the patient's consent, assuming that interventions presented to the patient were consented to unless otherwise indicated, which is most often the situation), may choose lesser degrees of intervention if presented with more unbiased facts. Such as, we have found massive bleeding in your abdomen. Our treatment for this condition is usually transport by ambulance to a larger hospital, infusion of blood products and fluids, (attempted) pain management, surgery, and a stay in the ICU. The possible complications include: uncontrollable pain or discomfort; multi system organ failure, shock, blindness (temporary or permanent), systemic thrombosis (clotting) due to rapid infusion of blood products resulting in stroke, heart attack, pulmonary embolism, deep vein thrombosis, loss of a limb or an organ, kidney failure, or rejection of blood products by your immune system as a result of the blood transfusions; surgical complications including infection, thrombosis, and/or death; and/or possible death in a moving ambulance, emergency department, operating room, or intensive care ward, possibly alone except for hospital staff. It is possible that you will not survive to leave the ICU following surgical, infectious, or medical complications beyond our control.
The likelihood of this treatment benefiting you is ___________%
The likelihood of a full recovery is ________%

We can also offer you some of the treatments available, such as the infusion of blood products but not surgery, or the infusion of fluids but not blood products. Or pain control but no other interventions.
In those cases, the likelihood of this treatment improving your outcome is lowered significantly.
The likelihood of a full recovery is almost zero.

With full interventions we can offer you a chance at another ______ years/months of life (life expectancy given the cancer(s) this patient already has).

Do you have any questions?
How do you wish for us to proceed?

In this case the ethical considerations presented in my previous post are not as simple as "does the patient want us to try everything?" The physician in charge really needs to fully grasp the implications of treatment and of non treatment and present these to the patient in as neutral a way as possible, because the physician's presentation of the possible implications of all scenarios may imply a more complex choice, lending itself to more careful consideration on the part of the individual patient. Implied in a more thorough and less biased presentation of possible choices is the weight of the decisions at hand. The option to not intervene is more positively presented, making it a better informed choice, in my opinion.

In this case, there was no family to consult.
In other cases, the patient may be nearing the end of terminal cancer, or unconscious. These factors complicate the decision making process.


Tonya said...

I guess I assumed he was unable to give consent to anything. When Katie was sick, they knew not to call the ambulance because, even with a DNR, it is hard to get them to not treat a dying patient. Fortunately, that decision did not have to be made. It just proves your point that we tend to automatically assume everyone wants the "full" treatment.

Hope I'm making sense. Pregnancy brain, early in the a.m. and I haven't had all my coffee yet. :-)

Dana said...

I would definitely want your scenario and would likely go with the "less is more" approach if I were in a situation like your patient. It seems it's hard to find someone who will take the time do present it that way!

tamie said...

I really really appreciate you informing us about all this stuff, Mel. I have a question. Is there a way for me to decide this kind of thing now, and to make it legally binding, so that if I was in a bad car accident or something, my loved ones wouldn't have the agony of making those decisions on my behalf? I have no idea how to go about putting that kind of thing on paper and making it legal. Do you know? (By the way, I completely agree with you that society tends to think that just keeping someone alive is a good in and of itself, and this seems unwise to me for many different reasons, which we should discuss over coffee sometime, whenever we meet!)