Posted on April 13, 2018 at 1:46 PM
by Craig Klugman, Ph.D.
Lots of medical dramas were on hiatus this week but will be back.
Chicago Med (Season 1; Episode 15): Saving one twin; faking a license; cost of care
A set of conjoined twins comes to the ED with one of the twins in heart failure. Their separation surgery is scheduled in 10 weeks to give the hospital time to be prepared and to give the twins time to grow and gain strength. But if one twin dies, the other one will soon follow. Latham says that if they try to separate the twins, there is no chance either will survive; but if they concentrate on just saving one—allowing the second to die in the process—then the odds for the one twin improve. Rose is trying to save both by suggesting a risky diagnostic procedure. Latham says the surgical team is behind the decision to save the one because it has the highest chance of success. Rose asks if they shouldn’t bring the choices to the parents, but he is struck done, the other doctors saying it is too difficult a decision. The team informs that parents of the decision and that there is nothing else to be done. As the parents say goodbye and the team preps for surgery, Rose goes behind the back of his team and offers them the risky option, which they grab onto. Rose performs the procedure and it succeeds because on this show, the ends justify the means. Latham tells Rose that he is a “diva” and not a team player. By going behind their backs, Rose proved himself to not be trustworthy and he is removed from the separation surgery.
This is a challenging case because so much about the patients (their internal anatomy) was not known and thus the risk could not be accurately assessed. The initial decision to not include the family in making the decision seemed problematic—shouldn’t patients/parents be involved with making decisions? On the other side, once the team makes a decision that is ethical and legal and based on the best medical knowledge, is there an obligation to support that choice and be a trusted member of the team?
What if we reversed the scenario and the team supported the risky option and Rose wanted to take the safe one? If the team decision was clearly wrong or dangerous, then going to the parents would be the right thing. But when the options are poor and there is no clear right or wrong choices, then supporting the well-reasoned choice seems to be of importance.
Story 2: Nurse Lockwood faces her hearing for acting outside of her scope of practice when she opened a patient’s chest to save her life. The hospital attorney suggests making the case that she was acting in her role as a paramedic and not as a nurse at the time. When Lockwood goes home to find her paramedic license she discovers that it expired two weeks earlier. She draws on some personal contacts to get a renewal; backdated so that it appears she was never without it. When Lockwood arrives for her hearing, she learns that there will be no repercussions for her actions and all was fine. Lockwood violated the law and ethics—she lied and she asked others to fake documents. There is an issue of justice, that simply for a piece of paper, she might have lost her career, but the rules are meant to ensure the safety of patients. The easy is not necessarily the right. Lockwood has regrets and feels that she betrayed her own values. I wonder if this action will come back to haunt her.
Story 3: A father comes in to the ED with stomach pain and shortness of breath. He is accompanied by his wife and son, who is a new student at Northwestern University. The patient forgot his antibiotics for diverticulitis at home and just needs a renewal. Halstead is concerned because the diagnosis does not match the symptoms. When the patient starts coughing up blood and needs a chest tube, Halstead orders additional tests. He diagnoses sarcoidosis. Throughout his care, the patient keeps asking about the cost of each test and choice: “How can you order all of these tests when you don’t know how much it all costs.” The wife tells him not to worry, that they have insurance. After his diagnosis, the patient asks his family to leave the room. The patient reveals that in order to have enough money to pay for college, he switched them to a cheaper insurance plan that does not cover this care since he is out of network. Halstead apologizes and says that everything he did was to save the patient’s life. The patient replies, “Well you shouldn’t have. At least they could collected my life insurance. Now what? We have to pull my son out of school. We’re ruined. You should have let me die.” The show leaves the viewer with these questions about the cost of care and who bears it; given a market-based hospital system, should a person be able to decide to die for a treatable condition to spend the money in other ways; is there a point where one generation makes a sacrifice of life for the benefit (in this case of education) to a future generation? If the son was asked, would he have chosen treatment for his father or continuing his education? My guess is the former.