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05/08/2017

BioethicsTV: Violating consent, living with difficult patient choices, and helping family choose

by Craig Klugman, Ph.D.

On Grey’s Anatomy (Season 13, Episode 22), two storylines looked at when a physician’s desire to do good should outweigh a patient’s choice. [Shortcut answer: Rarely] In the first storyline, a young woman enters the ED after falling down a flight of stairs while leaving the apartment of a one-night stand. She has an inoperable heart tumor and has decided to spend her remaining time being as hedonistic as possible. At one point, she turns to the doctors and tells them that she knows what they are thinking: That they alone can give her a chance; that there is some technique that only they can do. She explains that she has been through this situation 6 times and is very comfortable with her condition. Of course, her words are prescient. She agrees to a surgical technique that can possibly remove her tumor. However, the surgeons find they procedure more complicated than expected as the tumor is highly invasive and to remove it all would mean removing her ability to eat and perhaps to walk. The procedure debulks the tumor but does not cure the patient. When she awakes, the doctors explain what happened and Meredith Grey realizes, “You did this for us?” The patient smiles and says that’s how it happens every time. The patient goes under surgery to make the physician feel better. This story demonstrates that we do not train physicians to be with patients nor to accept when a person is dying (and is comfortable with that). Instead, we train physicians to always fight, to view death as the enemy, and that as long as there is a possibility of making a difference, they should do it. The result is that the patient may be permitting care so that the physician can accept that the patient is dying. This is the reverse of what the physician-patient relationship is supposed to be, a doctor caring for a patient. There is nothing wrong with mutual care, but undergoing surgery for a physician’s sense of well-being shows what is wrong in a society that refuses to acknowledge and accept death.

In a second storyline, a young child shows up at the hospital without any parents or guardians. He has a seizure and the doctors realize that he has an operable brain tumor which will kill him if left alone. After his parents arrive (presumably because a social worker tracked them down), we learn that they belong to a religion that eschews all biomedicine. They want to take him home to pray. The next day the boy returns to the hospital by himself and this time he is blind. He cries that he prayed as he was told to do, but the result was that he lost his sight. Kareev decides to lie and writes in the medical record that the boy was having life-threatening seizures that required emergency surgery. Under emergency consent, they would remove the tumor. The parents are horrified that their explicit values and statements were ignored. Bailey informs Kareev that he could go to jail. Stephanie, a resident, yells at the father that perhaps god’s plan was for the boy to come to the hospital to get help. She then throws a tablet past him and he tells her that she will be going to hell. Stephanie is reprimanded and loses her privileges until she gets counseling. At the end, we see the parents sitting on their son’s bed as he recovers.

This story has three distinct ethical issues. First, the lack of professionalism exhibited by the resident. The viewer is told that her outburst is because she never received counseling after earlier trauma she experienced. Stephanie realizes that her behavior was unacceptable. However, it is never proper to take out your personal demons on a patient. It is also never acceptable to throw things and berate a patient, no matter how frustrating one finds them. You can try to convince them and persuade them to make a different choice, but you cannot force them to make that choice or abuse them for not following your wishes.

The second issue is lying in order to cover up an unethical and illegal deed—performing non-emergent surgery on a minor against parental wishes. The lying is a cover up and this wrong is being excused for the greater good of saving the child. The lie is not only a statement but a falsehood entered into the medical record. The lie is not for the benefit of the patient, but rather for the benefit of the doctors who acted wrongly.

Third, the doctors operated on a patient without consent. In fact, they operated against the orders of the parents. If the doctors truly believed that surgery was in the boy’s best interest, they could have called for an ethics consult, or gone to legal and requested an emergency consent from a judge. Given the high expectation of cure in this case, a judge would likely have granted approval. Instead, the doctor’s let their ego and outrage make a decision that not only jeopardizes their medical license but has also placed the hospital at great risk of liability. The parents could press charges and have the physicians involved arrested for assault. Any one of these violations should have led to an instant suspension of hospital privileges, but that’s not how this fictional hospital works. There is likely a reason why we have never seen an ethics consult in 13 years on this show.

Chicago Med (Season 2; Episode 22) also had two storylines concerning the issue of consent and professional behavior of the health care team. In one episode, a young girl comes into the ED in respiratory distress. When it turns that she has a sexually transmitted infection the concern becomes that she was assaulted. All eyes turn on her stepfather as the culprit since statistically that is the likely assailant. Even his wife, the girl’s mother, thinks he may have done it simply because he and the girl spend so much time alone together. The discovery of traces of an anesthetic in her system leads the police to realize that the perpetrator was most likely her orthodontist. In most states, health care providers are primary reporters meaning that they are obligated to report suspicions of abuse of minors to the authorities. There is no requirement of proof, just a suspicion.

The second storyline involves a male pedestrian brought to the ED after being struck by a car. He has several fractures including in his spine and a brain bleed. After being told that his full recovery is likely to take a year, he refuses further medical treatment. The patient explains that he was diagnosed with ALS and within a year would be unlikely to walk and be dependent on a ventilator to breathe. He does not want the bleed in his brain fixed, even after being told that the condition would shorten his life to a few weeks. Nurse Sexton is outraged that he would not fight to stay alive and she tells him so. Administrator Goodwin let’s Sexton know that the patient has an “iron clad” advance directive where he lays out his wishes very clearly.

However, the case becomes more complicated when he starts having micro-clots that cut off blood flow to his extremities and some of his organs. The patient says that he has been living with the idea that he would donate all of his organs to save other lives. The idea that he would not be able to donate causes him distress. He still refuses the surgery. Choi offers him the option of heparin, which would preserve the organs but increase the rate of bleeding in the brain and shorten his lifespan to hours. The patient regrets that he won’t be able to say goodbye to his loved ones, but agrees to the heparin. Donating his organs is his most important value. Sexton refuses to enter the order for heparin. Goodwin talks to Sexton and explains that they do not have to agree with his choice, but his choice is clear, well written, and well communicated: He has the right to make his choice. Sexton is not only at the bedside when the heparin arrives, she is the one injects it into the patient’s IV.  We later hear that the organ retrieval went well and many people will be saved.

What struck me as remarkable about this storyline was that the health care team responded well to the patient. They talked to him about his situation; they listened to his wishes and reasons; they read his advance directive carefully; they challenge him by offering other options and perspectives; and when he made his rational choice, they helped him achieve a good death. The fact that such a good outcome is remarkable says a lot about how poorly our culture is represented in the media when it comes to end of life.

Mary Kills People (Season 1; Episode 3): “There is beauty in the inevitable” says the first assisted suicide patient of this episode. The main patient this week is Matt, a 33-year old male with cystic fibrosis. Mary visits him while he is talking to a surgeon about an aggressive surgery. The patient wants to talk about what happens if the surgery goes bad and he ends up in a vegetative state. Before the conversation goes further he has a crisis and ends up on “life support.” His sister is his medical power of attorney and she thinks that his doubts about the surgery are out of fear and a loss of faith that god will lead him to a cure. She asks Mary, “What should I do?” Mary says, “It’s not for me to decide.” The sister responds, “But you’re a doctor, you deal with this everyday; How do you decide when to keep going or when to stop?”  Mary tells a story of the patient at the opening to the episode, a patient for whom more could have been done, but that the patient knew it was her time. The viewer is not privy to the sister’s decision nor what happens to the patient.

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