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04/27/2018

BioethicsTV (April 23-27): #TheResident, #ChicagoMed, #CodeBlack

by Craig Klugman, Ph.D.

The Resident (Season 1; Episode 11): Placebos, CYA, Office politics; Chicago Med (Season 3; Episode 17): Promise-making, Denial Brain death (PVS or coma); Code Black (Seasons 3; Episode 1): Do no harm, HIPAA

The Resident (Season 1; Episode 11): Placebos; CYA; Office politics

We learn that the hospital’s motto is “Incredible things are happening here.” That’s ironic because the incredible clearly isn’t meant to be seen in a positive light.

Pravesh is rotating through the ED. His first case is a woman who looks up diagnoses online and then convinces herself she has the disease. He determines that she is perfectly fine and goes to discharge her when his attending says to pick one of her complaints and “write her some sort of placebo prescription” for it. Pravesh asks why he would do that and Feldman, his attending, responds that she needs to “walk out feeling better than she walked in” to make sure that she does not return tomorrow. Writing prescriptions for patients who do not need them is one of the reasons that there is a rise in antimicrobial resistance (one of many reasons). Also, writing a placebo on a patient is lying and in most cases, doctors to lying to patients is wrong. If the patient frequently visited the ED and had a psychological evaluation where treatment calls for a placebo, that would be one thing, but in this case, the suggestions was to avoid the inconvenience of the patient returning and having to talk to her about why she thinks she has all of these problems. In a twist, the patient returns at the end of the episode saying that she thinks she has lymphoma and wants to see an oncologist. The viewer knows that she does not have cancer, but the referral to oncologist Hunter makes us believe that Hunter will treat her anyway.

A long arc this season has been about Lily, a girl receiving a huge dose of chemo, who died. All chemo patient records are kept secret in Hunter’s private lab. When Lily comes in very sick, Nevin hung a slow drip of potassium as ordered. In this episode, we learn that all of the potassium was delivered at once, killing the patient. Nevin is brought before an inquiry board and she believes that the board is looking for a scapegoat and she’s it. The viewer knows that Hunter walked into the patient’s room after Nevin left and set the drip wide-open.

In a separate but related storyline, Hunter and Bell make a move to disgrace the hospital CEO. Concerned that she plans to go after people with error rates and install cameras in the ORs, they are concerned that she might catch them in doing wrong. In defense they try to blame her for an OR fire that burns a patient by saying she was too cheap to replace the anesthesia machine with newer ones. Hunter ends the scene by saying “our CEO needs to be an MD.” The Board takes those words to heart and appoints Bell as CEO whose first move is to fire Nevin. In yesteryear most hospital CEOs were MDs and this story arc seems to be a romantic calling for those years. An MD with the training and ability to be a good administration might be ideal. But an MD who is more interested in protecting his reputation than making sure patients are safe is far worse than the professional health care administrator. I would also argue that if someone is a good doctor who cares about their work, then taking them out of the clinic and into the boardroom may not be good for that person’s well-being and effectiveness in the organization. The viewer, however, knows that in this case the decision is for Bell and Hunter to continue their corrupt and maleficent ways, not out of any sense of altruism or administrative competence.

Chicago Med (Season 3; Episode 17): Promise-making; Denial; Brain death, PVS, or coma

Choi volunteers providing basic medical care to homeless kids in their encampment. He suspects one 16-year-old boy of having lymphoma but the kid won’t go to the hospital out of fear that the authorities will send him back to his adopted parents and that he could not bring his dog with him. Choi’s [adopted] sister shows up and says the teen’s care might be an emergency and they could make an exception. The kid agrees to come in. Choi reprimands her and tells her that she should not have done that: He may find something that requires him to contact the parents. She may require him to break the promise just made. Choi asks chief of psychiatry Charles what to do: The patient won’t give his parent’s contact information and oncology won’t treat without their permission. Charles asks if the teen is in danger from the parents and Choi did not think so. Choi breaks his sister’s promise. With the police’s help, Choi contacts the parents who come to the ED. In the meantime, the patient left with Choi’s sister to reconnect with his dog. Choi brings him back from the encampment to reunite him with his parents and get treatment. He agrees to come home if he can bring his dog. Choi thanks the sister for helping him understand the patient’s point of view. There were no repercussions from the promise since the ends always justifies the means in this show. In reality, physicians generally cannot make promises that they know they cannot keep.

A childwith severe abdominal pain comes in. The child has been previously diagnosed with PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections)—a controversial diagnosis not accepted by all medical specialties. Halstead is concerned because the boy’s doctor diagnoses a lot of children with PANDAS. He fears that a year on multiple antibiotics might be causing a problem with the pain. Tests reveal that the boy has “toxic megacolon” which was brought on by the long term use of antibiotics. The parents want him transferred to their specialist who will give him IVG., which Halstead believes will not do anything. Halstead believes the boy has an inherited neurological condition (without formal testing) and that the parents should not be coddled in this belief. Manning is willing to give them the IVG there (it won’t help but it also won’t hurt). As the story advances, the bowel inflammation worsens, to the point where the patient needs surgery or risks the bowel dying. When Manning sees the mom in the bathroom washing her hands until they bleed, she tells the mom that likely her son’s problem is OCD inherited from her. As his condition worsens, the mother finally reveals her disease to her husband and that their child never had PANDAS. The father consents to surgery and walks away from his wife, for lying to him about her condition and thereby putting their son in danger. Surgery goes well and the child comes through fine.

A bystanderof an attempted robbery was shot in the head. Rose intubates him. Stohl, the ED chief, declares the patient GCS 3 and then says “brain dead.” However, the chief is incorrect. A GCS of 3 can mean a severe disability or maybe a vegetative state. Such a patient might be in a coma, having no meaningful reactions, but would have sleep-wake cycles and some ability to arouse. So is the patient GCS 3 or brain dead: They are not the same thing. However, Rhodes sees a potential organ donor and upon learning that the man is an organ donor, immediately wants his heart. Stohl hears significant heart problems, but Rhodes believes he can fix the heart, taking the patient to surgery. Here’s where things get ethically messy, if the patient is not dead, then a surgery would require consent. The patient is unconscious, no family or surrogate decision-maker is around, and since the heart surgery is not emergent (not even meant to benefit the patient), then 2 doctor permission guideline would not apply. Rhodes is committing a battery. Bekker questions this choice, saying that the heart has problems and even with repairs, the recipient would die on the table. They do the surgery (assault), putting the patient on bypass and giving anesthesia. If they thought the patient was dead—why go to such efforts, the same as for any living patient? The transplant is a success. What we do not see is how the donor’s life ended—did they take it out of him as a GCS 3? Or as a brain dead person? Did they kill him for the heart? Do a donation after cardiac death protocol?  It’s easy to see how the public can find these terms and conditions confusing when they have television shows that only add to the perplexity. If the patient is indeed GCS 3 and not brain dead, then Rhodes likely murdered him for the heart.

Code Black (Seasons 3; Episode 1): Do no harm; HIPAA

The new season opens with a Diego Avila, first year resident, making a movie of his experience at Angels Memorial Hospital. Savetti tells Avila that there are HIPAA issues with carrying the camera around the ED. Savetti asks Salander (i.e. “mama”) why he doesn’t have a problem with the camera, to which Salander replies that he has bigger problems to deal with at the moment.

When victims from a shooting roll in on ambulances, Rorish asks the residents what the first rule is. One says “do no harm” to which Rorish replies, “Not here.” The rule in the ED is “we plug holes.” When Avila records an injury instead of helping a patient, Rorish tells him to never endanger a patient. Later, when a patient is complaining of pain and he is filming the patient, the new resident gives him a large dose of pain med that sends the patient into a seizure. Avila did not check the chart to find that the patient is allergic to the medication used.

Patient privacy is inconvenient, challenging, and necessary. Without the trust created by confidentiality, patients can be harmed if their information gets out—stigma, loss of job, insurance challenges, damaged relationships and more. Plus, without the trust of confidentiality, patients will not share information that health providers need to diagnose and treat. This show tried to show a balance between when privacy is helpful and when it seems to get in the way. Clearly filming a video without permission in a health care setting is a violation and the distracted physician was a danger to his patients.

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