Saturday, March 12, 2011

Mercy or Murder? Who Decides?

As I have mentioned in the past, whenever I work in Preop Holding, something strange or confusing seems to happen. One night last week it involved a hip repair on a 90 year old. Hip repairs or pinnings are something we see everyday, typically in elderly patients after a fall. However, this particular situation brought some very strong opinions out into the open.

Anyway, a couple hours before the scheduled surgery, I called the patient's floor nurse for a report.  Instead of reciting the usual vital signs and statistics, the nurse stated that she was unable to give me report. She told me that the patient's daughter refused to give consent for the operation and had just left to go home.  The floor nurse explained to me that the patient had advanced Alzheimer's and was therefore unable to give informed consent and all that legality nonsense. 

So, since I've been in Surgical Services awhile now, I immediately understood what was the most pressing concern here. Thus I let the OR charge nurse know the situation, so that the surgeon would not be kept waiting. Surgeons, I have learned through various tirades, really, really do not like to be kept waiting.  So now that I had my priorities straight, I could move on to other things, such as maybe finally getting to pee nine hours into my shift. But that was not to be. The orthopedic surgeon in question, with resident in tow, came storming into the unit, demanding answers that I did not have. I had gotten the daughter's phone number from the floor nurse, so I handed it to him and suggested he call her. Before he made the call, he ranted for a while about how the patient was being sentenced to death by her daughter, the patient would be dead within a week without the surgery, that this was the most ridiculous situation he'd ever encountered in his twenty years as a surgeon, etc, etc. His face beet red with fury, the surgeon stomped out of the room to call the patient's daughter.

The resident, left behind by his leader, was muttering about euthanasia being illegal while he checked his Facebook. I went into the OR office for an update. The OR team for the hip repair was enjoying their unexpected leisure time in the office, along with another team in between cases. All were loudly vocalizing their opinions on the daughter's decision, which had ignited a fiery debate on the meaning of suffering and end of life care.

"It's murder" said one nurse "I heard someone was gonna call the police and have the daughter arrested"
"She just doesn't want her Mom to suffer more" said a scrub tech "we all talk about people being kept alive for too long. The daughter is doing the right thing"
"She'll suffer more if she doesn't get her hip fixed" chimed in the resident, who had gotten lonely and wandered into the office, still looking at his Facebook.
"I'm with the daughter. I wouldn't want to live if I was bedridden with Alzheimer's" asserted the charge nurse, a twenty year OR veteran "I put my dog to sleep when he was eleven years old and needed a second knee replacement. I didn't want him to go through that. Why don't humans get that right?"
"This is not a dog. It's a human being. Hellooo! I think the daughter is no better than a murderer. She's cold" said a scrub tech.
"Check it out" said a nurse "this is how healthcare rationing is going to start. You know...the death panels. The elderly won't be able to get surgery anymore. They'll just have to die"

 At this point I went back to my little area of the hospital and started preparing the charts for the next paperless system here yet! Soon the orthopedic surgeon came back, and the resident stopped playing on his iPhone and started paying attention.  The surgeon explained that he had managed to make the daughter feel guilty enough that she okayed the operation for her Mom. He told me to get the patient downstairs ASAP and "Chop, chop". Yes, he actually said chop, chop.

We sent for the patient. I called the daughter to obtain a telephone consent. When I spoke with her, she impressed me as a caring, kind person. She was friendly and cooperative on the phone. Another nurse and I witnessed the consent. Then the daughter spoke with the anesthesiologist to agree to rescind the DNR order during the surgery. It was done in less than ten minutes. The patient was prepped and whisked off to the OR within twenty.

The patient had been unable to speak, but groaned and lashed out with her arms when I got her vital signs and hooked her up to some fluids. She got extremely agitated when I pulled TED hose onto her nonoperative leg. She did not seem oriented in any way.

I had mixed feelings about the whole situation. It is too rare that a family has actually discussed the patient's wishes before illness either creeps up slowly or slices into their lives with devastating suddenness. I have witnessed these talks only a couple of times, but felt privileged to see them. It takes courage and love to bring this stuff up. It is so much easier to live in denial, not wanting to think about our loved one being weak or ill, much less close to death. Declining a vent or feeding tube strikes me as a very common sense option when a loved one is terminally ill and unaware of their own identity or situation. Declining a hip repair, I'm not as sure. On a 90 year old with advanced dementia, maybe that's reasonable. But love and fear of loss can make it hard to think logically. I don't know what I would do if that were my parent. What would you do?

I'm sure as budgets are cut and healthcare costs continue to rise, money will also become more of an issue in these decisons. Studies have shown that a huge proportion of healthcare dollars are spent on end of life care, often prolonging lives by only days, and not happy days either. I think there are certainly many times that hospice is a better option than aggressive, invasive medicine. Often these patients are vented in the ICU  while their families are hoping the next, newest miracle drug or treatment will fix them. A 90 year old is one matter. What if the dying patient is a child?  It is heartbreaking for all concerned. I know it is incredibly hard to let go, but unfortunately as the money dries up, the healthcare systems may start making that choice for us.

We see patients on a daily basis with tubes in every orifice, decubitus ulcers, and a grim prognosis. We meet families who want everything done, rib fracturing chest compressions, tube feedings, rectal tubes, endless blood and platelet transfusions, every antibiotic under the sun, painful, but futile treatments to add a little more time to a life whose quality has declined to almost nothing. We grumble about how we want DNR tattooed on our bodies and sigh as we carry out the family's wishes.


  1. Great observations. Sometimes it's hard to sit back and not judge families decisions one way or the other.

  2. I am not so sure that there will be "death panels" in the future as everyone is predicting with the movement to socialized care.

    In canada we don't have death panels and we have had socialized medicine since the 1960s. I am seeing that the expeditures are higher in the USA with the system in place now - unsustainable.

    An Alzheimer patient with a need for hip pinning is difficult - not understanding what is going on or the pain - either way, whether there is surgery or not, it is doubtful that she will live much longer.

    Also, a cancer patient that is treated when obviously all it is doing is making life miserable - as you mentioned - without extending life by much more than a day or two - you have to wonder why it is done.

    Very difficult, the questions you raise. We think we know what the answers are, but to actually act on them is a whole different ball of wax...

  3. Yeah, there is a lot of grey area. I had always put the judge on the families of bedridden patients with PEG tubes until my own grandpa had advanced alzheimers and was walking around but refusing to eat. AIrway support is a pretty easy call, but watching him waste away but knowing it would be worse to do something was pretty horrible. I can't even imagine dealing with something like this.

  4. I'm an oncology nurse and see this sort of thing every day. People with stage 4 cancer who have exhausted all chemo/radiation come for bowel resections, debulking surgeries, colostomy placements, anything to extend that life for a few more months. Most of the time, all they gain is a few months tied to a hospital bed. I have coded way too many emaciated terminal cancer patients.

  5. What an ass of a surgeon - but what do you expect from an ortho?