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04/06/2018

BioethicsTV (April 2-6): #ChicagoMed; #GreysAnatomy

by Craig Klugman, Ph.D.

Chicago Med (Season 3; Episode 14): Record checking; off label use; scope of practice; Grey’s Anatomy (Season 14; Episode 18): Experimental treatment; Saying goodbye

Chicago Med (Season 3; Episode 14): Record checking; off label use; scope of practice
Psychiatry resident Dr. Reese figures out that her father is a diagnosed psychopath. Her attending, Dr. Charles apologizes to her, letting her know that he could not have told her because to do so would have broken physician-patient confidentiality. However, how she figured it out was by looking at her father’s chart. While Charles was ethical in preserving confidentiality, Reese demonstrated a lack of ethics by checking her father’s chart. In most hospitals, policy forbids health professionals from checking charts that are not those of their patients including friends, family, and themselves. The medical record is a legal document maintained via the ethics of confidentiality—a duty that Reese violated. In many institutions, this would be a fireable offense.

A middle-aged patient arrives to the ED with lymphoma. An oncologist brought to consult reviews the chart and says that the patient has received all of the therapy that could potentially help him. He suggested that Halstead tell the family the prognosis and offer hospice. As Manning says, “Hospice will provide…the best quality of life with the time that remains.” The patient says, “I always said I wanted to die at home.” Manning does some research and finds a single case where an experimental drug cocktail shrank a similar tumor. The case is anecdotal; there have been no studies and it is not FDA approved.  Halstead tells her not to do it: “What you are suggesting is bad medicine.” She says okay and approaches the patient anyway. Manning tells the patient and his wife that it is an experimental treatment and may have no effect on his cancer; it might even be harmful. She then asks for his verbal permission, but she does not secure written consent or IRB approval. Manning initiates the multi-drug treatment. Halstead confronts Manning for going behind his back and giving the drugs—she lied to him. What he should have done at this point was talk to his superior and risk management. But he does not. Within hours the patient dies from a reaction to the therapy. The oncologist brings Goodwin into the discussion, informing Halstead that this was off-label, unapproved use and they could be sued for the death. Goodwin wants to talk to Manning. Halstead, however, says that that the chart was wrong and that it was he who had found some evidence the cocktail might be efficacious and so he used it. Goodwin let him know of her disappointment and she was referring him to the disciplinary committee. Manning yells at Halstead for protecting her; she owns her own mistakes. She tells him that he is taking the blame only because she is a woman. In a deux ex machina moment, the oncologist reports to Halstead that the patient died of a heart attack and not a drug reaction but that the tumor actually shrank. Halstead says that it wasn’t his idea, thus trying to undo the lie he told.

In reality, drugs are used off label and can legally be used this way. Usually a health care provider should look for some evidence that the drug may help beyond a single anecdotal case. And the patient did give verbal approval, though written consent would have been a better choice. Oncology is not Manning’s specialty, though, so she ignored the evidence of an expert and her superior.

Halstead stated that the chart was wrong and the action was his, nor Manning’s. Making a mistake in a note is one thing, but knowingly falsifying this legal record is ethically wrong and could have legal repercussions. We know that the mistaken action was Manning’s and Halstead is lying for her. Lying to a colleague or to a superior is ethically wrong—how can anyone trust a health care provider who deliberately lies to cover mistakes or to protect people who make them. For quality improvement, liability defense, and being an ethical provider, admitting one’s mistakes, cooperating with investigations to ensure corrective measure to prevent them from reoccurring is the least that we owe patients to provide competent care in a safe environment. Halstead’s action cannot be excused even though his intention was to be the knight in shining armor protecting his beloved. As Manning points out, that might have made things worse. In this show, however, the ends usually justify the means even though in real life, that’s how people get hurt.

In another storyline, a patient is crashing and when no doctors are available, Lockwood, who is a nurse, cracks the patient’s chest. Dr. Sexton tells her that she was wrong; by policy only doctors can do that. The patient awakens with a several facial droop as a result of a stroke—the news is not good. An initial opinion shows that she acted outside her scope of practice and is put on suspension pending an investigation.

Grey’s Anatomy (Season 14; Episode 18): Experimental treatment; Saying goodbye
In this episode, Shepard and Koracick perform experimental surgery on a young child. They use a technique they have developed and tried on mice to nonsurgically eliminate a brain tumor in their patient. The method has never been used, nor even tried on a human being. They have not even tried it on a cadaver. When they ask the child’s mother for consent, Shepard speaks about the nature of this procedure and that it is dangerous but the only possibility for the child. When they leave the room, Koracick tells Shepard that she laid on the fear too thick. Her response is that she felt she did not emphasize the dangers of this experiment enough. This exchange raises the issue of whether the mother was given adequate information of the risks to make a well-reasoned choice for her child. Given the lack of options, more information would probably not have changed her mind. In addition, there was no mention of seeking FDA approval for this investigational new device, a step that they probably should have taken.

In a second storyline, a patient is admitted with advanced liver and heart disease. She has a DNR, advance directive, and a medical power of attorney completed. However, Richard harasses her to look at other possible treatments. He cannot accept that the patient seems to have made her peace and is calm about her death. He forces her to speak with two surgeons to see what other options they can take. We learn that the patient has been Richard’s AA sponsor for 20 years and his push to recommend further action is based on his own fear of losing this very close person in his life. Later in the show, he is able to see that he can continue to try to fight the disease and his patient, or he can follow her wishes and be with her through the end. In reality, Richard should not have been this patient’s primary physician because he has a close, intimate relationship with her that could, and did, compromise his ability to provide the best care for her. A second idea that this story demonstrates is that dealing with the death of patients is not easy for health care providers and they need support when there is nothing to be done except to be present and witness.

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