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06/04/2018

BioethicsTV (May 30, 2018): #CodeBlack Patient racism and DNRs

by Craig Klugman, Ph.D.

Code Black (Season 3; Episode 5): Patient Racism

A middle-aged-white patient needs an appendectomy. As he is being wheeled to surgery, he is beside the chief of surgery and a new trauma surgery resident. The patient is jovial and says he feels a connection with the resident. The patient states that he wants the resident to do his surgery. The resident responds that he is still learning and they are lucky to have the best surgeon in the hospital. The patient insists and says he does not even want the chief in the OR. What becomes clear is that the patient is making this request because the resident is white and the chief is black. The question of whether requests based on racism should be honored is not a new one. In this case, when the patient is under anesthesia, the chief does come into the OR to supervise the resident. The resident offers the scalpel to the chief who declines saying that he can do it. Shortly an emergency surgery pulls the chief away who, while performing his own surgery, observes the resident via audio and video. The appendectomy is complicated when the appendix bursts requiring the resident to move from a laparoscopic technique to opening the abdomen because he did not know what to do otherwise. The resident is incensed that he has been put in the position of operating above his comfort level and competency in order to accede to the racist request. The chief tells him that it’s important to act professional. The patient survives. Later in recovery, the patient thanks the resident who then explains how the patient nearly did not survive because he did the surgery. The chief is standing in the hallway and overhears this exchange. As the resident leaves the patient’s room the chief asks what happened to being professional. The resident responds that he is still learning and walks away.

Patients often make requests about who should treat them and who should not. If a female patient has religious reasons for not being seen or touched by a man, attempts are usually made to acquiesce. In medicine, religious reasons are usually given strong consideration. But, there are exceptions. For example, if no one else is available then the patient can forgo the procedure or use the person who is available. If the need is emergent, then such requests cannot always be honored.

A series of case commentaries in Pediatrics  suggests that following a request based on a physician’s race is problematic because it furthers a history of structural violence and racism, could diminish a minority physician’s sense of worth, and might violate nondiscrimination policies and laws. Most of the commentaries suggest that when the minority doctor is a resident (as in the case discussed in Pediatrics) the attending should address the patient and explain that the resident is an excellent doctor who will provide good care. In his commentary, John Lantos suggests that the reason for the request is important—if the patient’s concern is based on personal history (such as being a Holocaust survivor) then there might be a legitimate reason to honor the request, but if the motive is racism, then it should not be.

A 2016 Academic Medicinearticle suggested a 4-fold approach to these requests: “assess illness acuity, cultivate a therapeutic alliance, depersonalize the event, and ensure a safe learning environment.” As long as bias and bigotry against any group exists, such requests are likely to be made. Medical school and CME programs should offer training in how to respond to these patients. Hospitals should craft policies for these situations. But asking minority health care providers to “rise above” the insult and to treat the patient like any other fulfills one ethical precept—beneficence—while violating others—justice and dignity. Saying “just ignore the bigoted patient” gives tacit approval to the racism and thus adds to asking people to work in a toxic environment. Ideally, hospitals and doctors would take a stand and explain that they give patients the best doctor for their condition. The patient is free to receive this care or free to go elsewhere.

Code Black (Season 3; Episode 6): DNR Orders

A patient with end-stage cancer who is a physician lets a third-year resident know that he wants a DNR. A high school volunteer is in the room at the time. She leaves the room alongside the resident and asks him what a DNR order is. The resident’s response is that it is nothing she needs to worry about. Later she is walking with the patient around the hallway when he collapses. The volunteer immediately begins CPR on a DNR patient because the resident did not take the time to explain to her what that meant. When the patient later recovers, the patient tells the resident that he violated his rights to refuse medical interventions. The volunteer walks into the room and asks “why do you want to die?” The patient explains to her that as a physician, he knows exactly what the disease is doing to his body and his cells; his condition is terminal. He says that death is another passage in life and he wants to walk toward it with his “head held high and with control.” The volunteer responds, “I didn’t know.”

Patients have autonomy to write advance directives, POLSTS and to request DNR orders. However, the volunteer has no access to the chart and when she asked, no one explained the situation to her. In this case, both the patient and the volunteer were correct. The resident should have taken this teachable amount to explain to the volunteer instead of trying to protect her from knowledge of death. All too often our society tries to shield young people from this reality of life. In my Death & Dying class, a large percentage of students have not had someone close to them die and often harbor fears and misconceptions. This episode suggests that we should, as the patient says, understand that death is a normal part of life, that it can be beautiful, and that it should not be hidden away.

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