White Coat Underground

Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today’s case will be the first in an occasional series. –PalMD

Case:

Mrs. M is an 89 year old woman who resides in a nursing home who was admitted with confusion and lethargy. She has a past medical history significant for stroke, coronary artery disease, depression in the distant past, and no history of dementia. She has lost significant weight over the last 12 months. She participates in social activities with her fellow nursing home residents, but prefers to spend time alone. She is a retired registered nurse and a widow.

On the day of admission, her nurse found her to be much sleepier than usual, and when she spoke, she wasn’t making a great deal of sense. An ambulance was called and she was brought to the emergency department.

On evaluation, she was noted to be a frail, elderly woman who was conscious, but disoriented. Her blood pressure was slightly low, her heart rate was normal, and she had a low-grade fever. Her mucus membranes where dry, with minimal skin tenting. She was able to follow basic commands. Her heart was regular, her lungs were clear, and she had some vague, generalized abdominal tenderness.

Laboratory examination revealed a somewhat low white blood cell count, mild anemia, and white cells in her urine. She was admitted to the hospital for urinary tract infection with sepsis, and was started on intravenous fluids and antibiotics.

Throughout the night, she became more confused, and her systolic blood pressure dropped into the 80s (which is quite low). Repeat blood work showed an elevated creatinine (indicating poor kidney function), and mildly elevated cardiac enzymes. Her urine and blood cultures subsequently grew out two distinct types of gram-negative bacteria.

While the intern worked on transferring the patient to the medical intensive care unit (MICU), the senior resident went through her health records in more detail. The patient had filled out an advanced directive, which contained the following statement:

If I have a terminal condition I do not want my life to be prolonged and I do not want life-sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death.

She had also designated her niece to be her surrogate decision maker if she were to become unable to make her own medical decisions. Her niece had signed the advanced directive indicating that she had read and understood it.

The senior resident called the niece to inform her that the patient was not doing well. She also went over the contents of the advanced directive and let the niece know that her aunt’s wishes would be respected. The niece became upset, and demanded that “everything” be done, and specifically demanded that no “DNR” order be given. The resident gently explained that she would have to respect the written request of the patient. The niece stated that she was the only legal decision maker, and that she was calling her lawyer. She then hung up the phone. The resident walked into the bathroom, cried briefly, then returned to the floor.

Discussion:

There is a clear conflict in this case which needs immediate resolution. The patient is in extremis, so this can’t wait for morning rounds.

1) What can the resident do to get help making a decision?

2) What are the salient medical facts that inform her decision?

3) What ethical principles inform the actions of the doctors and the surrogate?

4) What would you do?

Comments

#1 D. C. Sessions
January 26, 2009

Damn. It all hinges on whether the “terminal condition” clause applies (NB: my own is based on explicit prognostic consensus of three physicians; that’s the Arizona standard wording.) That in turn depends on the diagnosis.

Surrogate doesn’t know the diagnosis, doesn’t know the prognosis, and thus is way out of line.

I don’t know the diagnosis (except that it sounds like there might be a treatable infection involved) and therefore have no further basis for forming an opinion.
#2 PalMD
January 26, 2009

Cop out!
#3 Joe
January 26, 2009

I am not sure if you meant this for a general audience. Reading your description, I could not tell that the patient was in extremis.

A reason I respect you is that my dubious judgments go into the chemical-waste bucket; no questions asked. Your decisions have more profound repercussions.
#4 PalMD
January 26, 2009

TO give a little clinical background, a patient with these findings has “severe sepsis”, which carries a dismal (although not 100% fatal) prognosis–and that prognosis is changing rapidly, not for the better.
#5 PalMD
January 26, 2009

Actually, she meets the definition of septic shock…ever more dismal, but of course, while someone is still alive, you can never say that they will be killed by their illness with 100% certainty…so you have to make a judgment.
#6 Infophile
January 26, 2009

Well, I can’t answer the first couple questions well without more knowledge of how the systems works at a hospital, but here’s my personal opinion:

The advance directive lists the patient’s own wishes, and these should be given priority. The reason someone would have a surrogate decision maker is for an unforeseen case which isn’t covered by the directive. The responsibility of this decision maker is to make the choice they believe the patient would make if they were of sound mind.

In this specific case, the situation is covered by the advance directive. There is no need to appeal to the surrogate for a decision; the patient’s wishes are already written down and known. If she wishes to be given no artificial support, we must respect her wishes, however much we might wish for her to live. The niece, although I’m sure acting out of love, is acting contrary to her aunt’s wishes. She is not making the choice her aunt would want; she’s making the choice she wants. In the end, it’s the advance directive which should be followed.

That being said, I hope there are some rules somewhere about the relative priority of these forms of decision-making. If it isn’t clear that the directive takes precedence over the surrogate’s wishes, then there could be a problem. However, having that be a firm rule could also be a problem – what if, after signing the directive but before having to go to the hospital, the aunt feels a new lease on life and has an extra reason to live? For instance, her daughter might have just gotten pregnant and she’d like to live to see her granddaughter born. In this case, the niece might have a good argument that the aunt’s wishes would be different now than they were when she wrote the advance directive. That isn’t the case now, but it’s worth considering.
#7 D. C. Sessions
January 26, 2009

Cop out!

Not at all, Doctor — I’m staying within my scope of practice:

1) What can the resident do to get help making a decision?

Haven’t a clue (other than an ID specialist) — unless the hospital has an on-call legal office. Not a bad idea, that, but I have no personal knowledge.

2) What are the salient medical facts that inform her decision?

Not my field, and a man’s got to know his limitations.

3) What ethical principles inform the actions of the doctors and the surrogate?

See above — this I can address, and per your following comments the advance directives are binding.

4) What would you do?

Avail myself of the counsel (or Counsel) available, treat the infection aggressively, and issue the DNR in accord with her wishes and my best judgment of her chances for recovery.

Which, please note, my own advance directives make quite explicit: if the consensus of the MDs on the case don’t think I’m going to be discussing it with them after the fact, they don’t do it.

Which reminds — how many of us have advance directives? My 23yo daughter just filed hers and I’ve handled some really nasty trauma cases in their 20s, so age is no excuse.
#8 SB
January 26, 2009

Unfortunately, we see this situations much too often. As a chief resident, we have a couple cases like this every few months discussed at M&M and ethics conferences. But to answer some questions …
1) The resident in this situation should be able to call the attending physician. Not that the attending will necessarily have more answers – but they may have a better idea of what services are available in the hospital at night. If the attending is not available … call chief resident and/or administrative attendings (program directors). Sticky situations warrant getting more experienced physicians involved.
2) The medical facts .. this patient’s prognosis is very poor at the moment. Unfortunately, overwhelming infections of this nature in frail elderly are usually fatal. It is the unlikely that a patient will survive to discharge, and exceptionally rare that she would resume her previous state of health. Given the information, in my medical judgment I would consider her condition likely terminal.
3) I think the biggest ethical principle at play here is patient autonomy. The patient has previously made this judgment not to have life sustaining measures. The resident has a duty to beneficence and non-maleficence. In terms of beneficence the resident has a duty to preserve life … however, not at the cost of patient autonomy and in this case, the prolonged suffering that may occur would be maleficence. However, this all hinges on the judgment that the event is terminal.
4) Given my previous statement, I think it seems clear I would respect the patient’s wishes to not have life sustaining measures if I was convinced that the situation is terminal. However, I said it is likely terminal. I think I would try life sustaining measures for a day or two, see if she is turning around. If she has not made improvement, this would confirm that this is a terminal event for her. At that point, I think it would be reasonable to cease life-sustaining treatments in accordance with the patient’s wishes. As a side benefit to this approach, the niece would have a chance to see her aunt, discuss the prognosis with the medical team, and it would give us some time to dig into the issue of why she is opposed to her aunt’s wishes.

did I cop out? maybe …
#9 The Perky Skeptic
January 26, 2009

…damn. Makes me think the answer for me personally is to leave only an advance directive, without designating a family member who, in their grief, might mess up my sound-of-mind wishes!

I’d get another doc to add their opinion on the patient’s condition and chances for recovery to make certain the situation warranted following the patient’s advance directive, and treat her according to our best medical judgement. Then call the hospital’s legal counsel to let them know the situation.
#10 Dianne
January 26, 2009

1. The first step is to call the attending physician. And the resident should have no hesitation in doing so: any attending who would get upset about getting this sort of call has no business working in a teaching hospital. If the attending is stumped as well, as s/he may be, many hospitals do have a 24 hour emergency ethics consultant. Call them. If all else fails, hospital legal staff is also generally available 24 hours a day.

2. Urosepsis in a nursing home patient with not one but two gram negative rods and septic shock is bad. Very bad. However, it is treatable and, anecdotally, can be successfully treated. (Ok, the case I’m thinking of was only one bacteria, but it was E coli 0157 urosepsis in a 90 year old…who eventually walked out of the hospital.) The point being that one could, with only minimal self-deception, classify this as a not necessarily terminal illness. A very severe illness which very well may result in death, but not an inevitably fatal illness. Yet.

3. I’m skipping this question because it’s giving me flashbacks to all the horribly boring ethics courses I’ve had to sit through to be able to be involved in patient research. I definitely approve of making sure that researchers treat their patients and normal controls with dignity and act in the patients’ interests, etc, but if I have to read through one more summary of the Belmont report I’m going to…not really relevant here.

4. Ultimate cop out. As you can probably tell from #2: I’d treat aggressively. This illness could be survivable. Realistically, the probable result of aggressive treatment would be getting the patient stuck on a ventilator and pressors for some time until the patient’s niece agreed that it was, indeed, futile and allowed care to be withdrawn. Nonetheless, I think that this solution actually provides a way to respect the wishes of both the patient and her niece. Everything is done while the outcome is in doubt but when/if it becomes truly hopeless then care is withdrawn and the patient is allowed to die “naturally” as she wished. If the niece doesn’t face reality after a reasonable amount of time then further intervention via social work and possibly legal counsel may be necessary but 99+% of the time, relatives like the niece as described just need some time to get over the shock of suddenly hearing that their relative is dying to be reconciled to reality.
#11 N.B.
January 26, 2009

1) Others have already mentioned “call the attending physician.” Obviously, it would make sense to converse with other residents and physicians involved with the care of the patient; where else are you going to get a second opinion on ethics in a hurry?

2) I assume you mean “what are the facts that inform the resident’s decision,” since the pronoun is ambiguous. The patient isn’t doing well, but sepsis–and even septic shock–is not necessarily fatal. However, the prognosis isn’t good; the patient’s odds are very poor. The patient’s age, renal function, and presumed hepatic function all suggest that even if she “gets better” that the rest of her days will probably not be very comfortable. No matter what happens, the patient is going to have to deal with the lasting impact of a serious infection. Organ damage is assured, and no 89-year-old is getting a transplant. The patient’s remaining days, no matter how many they are, will not be exceptionally comfortable.

3) Patient autonomy is paramount here; beneficience takes a backseat to a patient-requested DNR order. The patient has expressly stated that she does not want to live longer than necessary in the face of terminal illness. While sepsis is not necessarily terminal, the odds are bad enough that it is not unfair to say that the patient is dying.

4) The patient’s directive makes it clear that supportive care above and beyond palliative measures should not be administered. However, I’m not one-hundred percent on the legal issues involved or whether the patient’s directive would eliminate liability on the part of doctors who decided not to intervene.

If I only had a few hours to decide? If I were certain that no intervention was going to help, I’d let her illness run its course, likely to the end of the patient’s life, and make sure she was sufficiently medicated for the sake of comfort. If I had a chance to consult a lawyer and knew the patient was going to live long enough for me to seek legal counsel? I’d want to make sure that following the patient’s DNR “directive” wasn’t going to get me in trouble. Assuming it wasn’t, I’d make sure that her wishes were followed–again, if I could be reasonably certain that her odds were so bad as to warrant not treating her aggressively with antibiotics that were ultimately going to worsen a lot of her preexisting organ failure, depending on the organisms isolated (sounds like enterococci, probably E. coli plus some other agent since it started as a urinary tract infection).

Of course, this is never going to be in my hands, what with my being a pharmacist and not a physician, and I’m somewhat thankful for that.
#12 jenjen1352
January 27, 2009

From a lay person’s viewpoint: the patient is a widow in a nursing home, and a retired registered nurse. I would assume that she would be more than capable of making a sensible decision about her own fate. The niece should stop thinking about herself and consider the situation from her aunt’s perspective.

I have been in the niece’s position. I made sure that my mother’s wishes were fulfilled.
#13 moneduloides
January 27, 2009

1) What can the resident do to get help making a decision?

Talk to one of the lawyers employed by the hospital to determine what legal courses of action can be taken to assure the wishes of the patient are realized.

Slash, talk to one of the lawyers employed by the hospital to determine how to go about not getting sued by the niece.

2) What are the salient medical facts that inform her decision?

The illness is severe, but by no means terminal. DNR isn’t really called for in this case.

3) What ethical principles inform the actions of the doctors and the surrogate?

The patient is the only individual whose needs must be looked after. Doctors do not treat surrogates, they treat patients. So, unless their is absolute legal necessity (see, your ass getting sued) then I would say the ethical principal that informs the action of the doctor is the advanced directive.

4) What would you do?

I would simultaneously treat and talk to a lawyer. You can’t take back the damage caused by not treating.
#14 Airedalelover
January 27, 2009

Wonderful discussion. We were faced with this decision for my mother-in-law this summer. Once we understood the medical situation we stopped all treatment save for pallative measures. She died peacefully a few days later. The visible relief on the part of the RN and the attending when we told them our wishes was amazing. I think they were ready for a battle when they came into the room.
#15 cre8tivewmn
January 27, 2009

I’m not a medical person, but I would like to comment anyway. The question is very interesting, but I find the discussion depressing, not because the old woman is ill and likely to die, but because her wishes may not be followed even though she expressed them and went over them with her surrogate.

I’m a control freak and the idea of having someone else in charge of something so important is very scary. I’d like to think that an advance directive was just that, but life can get so much more complicated.

It’s early yet. I would try antibiotics specific to her infection to see if she will respond (I wouldn’t consider drugs “artificial”), I would consult the physician and the lawyers to prepare for possible problems with the niece, but I would issue a DNR and I would not use a ventilator or other machinery to prolong her life.

And we should all make sure our advanced directives are as specific as possible and that our surrogates understand our wishes.
#16 PalMD
January 27, 2009

Don’t worry, cre8tive, i was hoping nonmedical people would chime in as well. I’ll give my own thoughts later, but i’m really enjoying the responses so far.
#17 MikeMa
January 27, 2009

Fascinating dilemma. My SO is studying for an MSW degree and she and I discuss these ethical issues sometimes. So far, I like the idea that while the patient is almost certainly terminal, it makes sense to try a few things to fight the infections/bacteria before giving up. This is especially true as her life prior to falling ill was not empty. The medical directive should be followed over the niece’s objections once it was clear that the disease was winning.
#18 Dianne
January 28, 2009

I’m curious to hear Pal’s take on the issue. Also disturbed to realize that I don’t actually know whether, in a case of conflict, the living will or the wishes of the surrogate has legal precedence…What if the conflict were the other way around? Suppose the aunt had left a document saying that she specifically did want aggressive care up to the point of brain death and the niece was saying “just keep her comfortable”? Would that be a different dilemma? (In other words, is there a bias for or against continued treatment in the face of horrible odds?)
#19 The Perky Skeptic
January 28, 2009

I have to say (not that anyone asked) that in the patient’s shoes, I think I would rather die of the infection than have the infection cured but need dialysis for the rest of my probably severely limited days.
#20 Dianne
January 29, 2009

Just to note that renal failure and dialysis in an acute situation does not necessarily mean lifelong dialysis. Acute kidney failure with a reversible cause (infection, stones, treatable tumor, DIC with a treatable cause) can often be temporary and dialysis may be needed only for a few days, weeks, or at worse months. This lady is in a bad situation because of her age and possible chronicity of infection (who knows how long she had an asymptomatic infection that no one noticed) but she doesn’t (yet) definitively have chronic renal failure. If that helps clarify and/or confuse the issue any further.
#21 PalMD
January 29, 2009

The conversation has been excellent. Here’s my take. First, remember that right and wrong are a little fuzzy, and that ethics is a way to problem solve, not coerce.

The patient has a 30-40% chance of surviving this immediate episode, if she is lucky. The numbers for a meaningful recover are even lower, and we must take into account the patient’s stated/written wishes to avoid futile care. We don’t have the luxury to ignore the niece. We need to explain that her duty, as surrogate, is to help implement her aunt’s wishes. We can help her do that in such as way as to help her feel more comfortable with it.

It wouldn’t be unreasonable to try treating the aunt with aggressive intravenous hydration and antibiotics, and to tell the niece that this is everything that can be humanely done…but that beyond the above very aggressive therapy, a DNR order would be more congruent with her aunt’s wishes in this situation.

Keeping the niece in the loop as much as possible is often helpful, making her feel part of the team (doesn’t always work of course). As soon as you cross over into an adversarial relationship, all becomes more complicated.
#22 Dianne
January 29, 2009

It wouldn’t be unreasonable to try treating the aunt with aggressive intravenous hydration and antibiotics, and to tell the niece that this is everything that can be humanely done…but that beyond the above very aggressive therapy, a DNR order would be more congruent with her aunt’s wishes in this situation.

It might be useful to give the aunt more details. For example, to explain that a DNR order is not a comfort care only order: her aunt can still be treated aggressively up to the point of intubation or recessitation. This might relieve the niece’s anxiety. Maybe she thought that her aunt wasn’t being treated at all, perhaps due to age prejudice or some other factor? People will often take up an aggressive stance when their frightened but may be more reasonable if you talk through their fears a little. Of course, this is all quite difficult for an overtired resident to do in the middle of the night. Again, I would suggest getting the attending, the social worker, and maybe the ethics consultant in on things early.
#23 cre8tivewmn
January 30, 2009

Dianne: If the situation was reversed, I would still go with the wishes of the aunt. If she wants to fight death for all she’s worth, who am I to say no?