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Ethical considerations (the real post) - Nobody wears a white coat any more...
...a tribute to becoming a doctor.
ayradyss
ayradyss
Ethical considerations (the real post)
Spent two weeks as Chief of Medicine recently, which is a sort of junior faculty position. You spend a lot of time seeing patients, and you're supposed to teach the other residents. It's a great way to learn just how much you don't know about medicine.
Two case studies to talk about, both from what I learned and from the questions they present...this is the first.

F came into the hospital via EMS after being found unresponsive on the sidewalk. The story he gave us the first day was not so simple.

So he says to me: I got this letter from the PNA inviting me to a firing squad on Saturday. So this Saturday I got in my truck and I drove out to the suburbs and they were way out there, at this house. It was me and a half-dozen other guys. They dumped me in a trench, and the guys said "How long you been here?" And I said "About 30 seconds."
They lined us up so they could take our temperatures and stuff, and they checked my blood pressure and they said "Man, your pressure is too high. You need to go to the hospital." So they loaded me and three other guys up on a flatbed truck and took us to the ER.
I hear they're telling people they found me outside my house, but that's not true. Where is my truck if that's true?


The term, O Best Beloved, is fixed delusion, and it means good luck talking him out of it. And this man who otherwise was completely with it and oriented ($hospital, room $room, Doctor...) seemed condemned to live believing he'd been rejected from death by firing squad.

The next day I walked in and he was most apologetic. Listen, Doctor...I guess I had it all wrong. I talked to my neighbor and he got me straightened out. Guess it was a dream...but it all seemed so real.
Our best guess is that he had a cardiac event (that's Medical for either a heart attack or a serious arrhythmia) and suffered a complex sort of hallucination while his brain was figuratively gasping for air.
Once we got the firing squad worked out, he was a nice guy, pleasant, adamantly a No Code Blue. The sort of patient you're sure Something Bad is going to happen to, so it was no surprise that he required dopamine support for his blood pressure, and then his kidneys failed, and he just sort of faded away.

Well...The first time he tried to die on us I made the mistake of asking someone in the throes of oxygen deprivation to confirm a no code, and got "Give me a tube."
So what do you do? (I'll give you a hint: I shouldn't have asked in the first place.) We called his daughters, the power of attorney, and discussed it. They were scrambling to get to his bedside from the other side of the country, a few days before Christmas, and they were adamant. "Dad doesn't want that." And we hemmed and hawed and decided that intubating the patient would be (a) futile, since it wasn't his lungs that were failing, and (b) not in accordance with his previously and repeatedly stated wishes. The nurses were ready to kill me for asking. The first-year whose patient it was was frozen with indecision.
We called Respiratory and put him on BiPap, which is the last step before a tube, and he got a little better...better enough to rationally reconfirm his No Code Blue and his Do Not Intubate. Better enough, in fact, for his daughter to make it to his bedside. And when she did, we started weaning his dopamine and turned off his lab draws. We talked him through his as-needed morphine order (one of the things morphine does, O Best Beloved, is reduce air hunger - stop the horrible feeling of suffocation that comes with low oxygen levels) and his daughter the Hospice-trained home health aide made things easy.

He didn't make it out of the hospital alive, but when he died it was with his daughter at his side and with as much dignity as one can muster in a hospital bed - quietly, in peace.

If he hadn't asked for the tube, I wonder if I would have thought to put him on BiPap. I wonder if we would have been quite as aggressive in our management. I wonder a lot of things. And in the end I think that we did the best we could do, and it was the best thing for him and his family.

A good death is one with dignity and peace, a death without fear. And it is possible to achieve. In the process of learning to heal, every now and then I am privileged to be touched by a good death.
3 whispers echo . o O ( ... ) O o . whisper a word
Comments
jillofthejungle From: jillofthejungle Date: January 13th, 2008 09:05 pm (UTC) (etched in stone)
Wow. I'm not sure how to respond to this post, but I had to. I'm just...blown away that you deal with things like this, things that seem like they shouldn't be real - that they should just be an episode on a TV show or something - yet are obviously so personal and intense and...I don't know.

I am utterly in awe of the fact that you deal with this and that you can deal with this.
fyrfitrmedic From: fyrfitrmedic Date: January 13th, 2008 09:37 pm (UTC) (etched in stone)
[nodding] such are few and far between, it seems.
leon03 From: leon03 Date: January 14th, 2008 04:00 pm (UTC) (etched in stone)
Well, the upside of asking and the resulting confusion was that his daughter got to be by his side. That means something. Even if he was hallucinating and then if he had given a different answer in a "normal" state of mind, the mystical side of me says that his was a genuine response and served a higher purpose.

The two interesting bits of information here was how he feels, and his daughter feels. Obviously we can only speculate about the former, but perhaps you should share this story, in some form, with the daughter and find out what she thinks, especially "should the question have been asked" Maybe this is against medical etiquette, as I know nothing about that.

Take care!
3 whispers echo . o O ( ... ) O o . whisper a word