by Craig Klugman, Ph.D.
This week appears to be advance directive week on television. First, on the rebooted X-Files, Dana Scully finds her mother’s advance directive. Second, on Chicago Med a physician ignores not only a DNR, but a patient’s clearly stated wishes not to be resuscitated. One of these presents a model of a good surrogate decision-maker who respects the patient’s wishes. The other shows an arrogant doctor who blatantly ignores patient autonomy.
The X-Files (Season 10, Episode 4) finds Agent Scully at her mother’s bedside after receiving a call from her brother that their mother is in the hospital. Mom is unconscious, intubated, and on a ventilator. Dana tells her brother that he should get on a plane and that it was their mother’s wish to remain on the ventilator so that her children could gather. A nurse walks into frame and tells Dana that her mother wrote a new advance directive in the last 2 years, which states she did not want to be on a ventilator, or intubated. She also wanted a DNR. This new document surprised Dana who wonders why her mother would change her mind and not talk to her about it (besides being an agent, Dana is a medical doctor). The nurse explains that just because they extubate does not mean, her mother will die immediately. In this scenario Dana wanted to keep her mother alive—she wanted the family to have time to say goodbye, she wanted more time with her mother so that she could “ask the little questions,” and because she wanted to understand why her mother changed her end-of-life care choices. Even with her concerns, Dana acts as a good surrogate, making the decision that her mother wanted. The patient is extubated and does not die immediately, but only after hearing the voice of her long estranged son on the phone. As someone who conducts clinical consultations, I wondered why even if the advance director, the hospital would not agree to keep her mom on the vent for a few hours or a day so that the family has time to gather and say goodbye. That is a practice I have often seen and think that it helps both the family and the patient.
Mrs. Scully’s dying was done surrounded by her daughter and ex-son-in-law. She offers a life lesson to her daughter on the value of family and the responsibilities that we have to those people and ideas that we create (a theme that is echoed in a parallel monster storyline). Her death is peaceful, allowing the dying person to have closure (even if the family does not) and her wishes honored.
The opposite outcome occurs on Chicago Med (Season 1, Episode 109). A mother comes to the hospital after a bad fall. She is unconscious with bruises and a broken arm. The patient has a DNR order (and likely a POLST form) as she has been treated for cancer for 4 years. She has been through several experimental trials and tried every chemical available. Her husband and daughter do not want to see her go and the husband is not a strong advocate—he tends to waiver at choices and does not make decisions. The patient is strong in her beliefs. She has the documentation and she clearly says to all health care providers that she is done: Under no circumstances should they resuscitate her.
A young physician, Dr. Will Halstead, lost his mother to cancer when he was a child. While flirting with a pharmaceutical representative, he learns of a “promising” experimental trial for a new drug to treat the same cancer as the patient has. He even manages to get a space for the patient in the trial. He is concerned when the patient says no to this opportunity and then tries to convince the husband to override the DNR so that the patient can enter the trial. The husband never says that he wants to override, but he does say that he doesn’t want to lose his wife. When the patient codes, rather than listening to the patient, Halstead performs a resuscitation. His colleagues are telling him to stop, that he’s not following the patient’s wishes. As he later states, his job is to save patients. The resuscitation requires an intubation and restarts the patient’s heart. She is going to have the kind of ICU death that she wanted to avoid. As the patient stated earlier in a moment of foreshadowing, when the doctors suggest admitting her for observation and plastering her arm, she felt like if she went further into the hospital than the ED, that we she would never come out. The look in her eyes when she finds herself alive and intubated tells the viewer that she is unhappy that the doctor did not let her die. This is further proven when the family sues the hospital and pursues battery charges against Halstead.
After being reported by his colleagues, the hospital administrator reprimands Halstead and tells him he won’t be suspended or fired because the hospital cannot have an appearance that anything was wrong. And after the case is done, he likely would lose his position. Rather than humility or remorse, Halstead states confidently that the family will drop the suit after the drug trial saves her life.
Here is a doctor who believes a clinical trial will save a patient’s life when in reality that is not the intent of a trial. His magical thinking causes harm to his patient. In this case, a paternalistic physician overrides patient and family autonomy. He acts on his own because he feels he has the power to save her and having lost his own mother to cancer, he wants to “save” another child from having the same loss.
The public often learns about medicine and health from popular media. For those lucky enough not to have had many experiences with hospitals and doctors, these shows may be all that they know of the medical world. Seeing two conversations and presentations of end-of-life wishes where both are dealt with sensitively and appropriately is beneficial to public education. Although Halstead acted unprofessionally (unethically, and maybe even illegally), the fact that he is being punished for those actions demonstrates the importance of taking end-of-life choices and planning seriously. The administrator perhaps overstates the power of advance care planning documents when she says that they are legally binding, but her words demonstrate that we should all take these documents as expressions of the patient’s wishes and that creates an ethical, if not legal, bond. How these two shows will ultimately deal with the repercussions of these deaths remains to be seen. If Halstead turns out to be right and his patient survives (and is thankful), then Chicago Med will once again have harmed the cause of education in medical ethics to the public. But if Halstead is punished then the cause of education will have been furthered.