Posted on April 12, 2019 at 3:54 PM
by Craig Klugman, Ph.D.
Exploring the bioethical issues in medical dramas
In the midst of a storm isolating the hospital, without power or blood, Sharpe tells Max he has to decide which patients they will save. He wants to save everyone, but Sharpe explains, “Your job is no longer to save everyone; it’s to try to minimize the damage.” They have to decide who to save, who to give the few resources remaining. Max refuses to make the choice, so Sharpe says that she will. However, in a deus ex machina moment, the power comes on and the tough choices are avoided. Sharpe is correct, in a crisis situation with limited resources, often ethical decision-making has no choice but to shift from saving everyone to reducing morbidity and mortality. Thinking must switch from medical ethics to a public health ethics. Sharpe’s concern about Max though is that “sometimes you have to choose, and you couldn’t.”
Part of the reaction to this crisis is to have visitors and more ambulatory patients help out patients with greater need. A second reaction is to rely on less technological interventions. In this case, a surgeon who had operated in war takes the lead on performing cardiac surgery. And an older physician, trained before most of the machines existed, offers guidance on providing care to patients that does not rely on the newer, electrically-powered tech.
In a black out, Elliott is an elderly man and retired astronomer who has Stage 4 lung cancer on home hospice. His daughter is performing CPR when Warren (a firefighter-anesthesiologist—former surgical residential) finds her and takes over compressions (Warren is in the building on a different call). Elliott has been down at least 20 minutes. When he regains consciousness, Elliott asks, “Why the hell didn’t you let me die?” Later, when the daughter is out of the room, Elliott tells Warren that he does not want to live anymore because of pain and fatigue, but has not informed his daughter because he thinks it would harm her. Warren asks if the patient has a DNR. Elliott says “yes” but his daughter walks in the room and says “No, absolutely not.” Warren talks to the daughter and says they joke about his dying but no real conversations. When Warren asks about a DNR, she responds that they “kind of have one.” They drew up some documents naming her the power of attorney but she never signed it. Warren tells Elliott, “Without a DNR, we have to take extraordinary measures to keep you alive.” Warren gives him the worst-case scenario about dying in the hospital hooked up to machines, which the EMTs have to do unless there is a signed DNR. His colleague pulls Warren aside and warns Warren that he is pushing the patient to have a DNR, which is allegedly against the law. Warren says he is only trying to show the patient his options. Later, a gas leak necessitates moving the patient and his equipment but Elliott states loudly that he does not wish to be moved. However, they ignore him. Elliott finally tells his daughter directly (she apparently hasn’t been hearing him telling EMS that he wants to die and does not want treatment). She says he doesn’t understand and that she’s not ready. Elliott begs her to sign the DNR order. We are told this means no transfer to the hospital and when the batteries run out of his breathing assist device, that no efforts to resuscitate him will be taken. The daughter signs the document and the rescuers move him outside the building, laying him on the grass to watch the stars. He dies lying next to his daughter.
Although this is not a show we normally cover, a reader notified us of the DNR plot line. While we applaud the show taking on this topic, the coverage is so inaccurate as to be dangerous. First, after resuscitation, the patient is coherent, logical, and can express himself. No documents are necessary: Elliott can state what he wants including refusing transfer and medical care. Second, a DNR order means “do not resuscitate” and is a physician-written order for patient care during a hospital stay. A patient /surrogate does not sign the order. The order does not name someone a health care surrogate. The order has no effect outside of the hospital. Thus, the order is not in effect in a person’s home. Even with a physician signed DNR order, the EMTs would have to resuscitate and transfer the patient because the DNR has no force outside of the hospital where it was written. Third, the document where one names a surrogate decision-maker is a durable power of attorney (in Washington state where this show takes place). This is a document that the patient signs (and in most places, has witnessed or notarized), but does not require the signature of the designated surrogate (though, it could be argued that a proxy’s signature to agree to the role would be a good thing). Instead, what Elliott should have is a POLST. In Washington state this is a Physician’s Order for Life-Sustaining Treatment. The POLST is a document that stays with the patient, expresses their end of life wishes, designates a proxy decision-maker, and has a physician’s signature (nowhere does the designated proxy sign). What’s important for this specific scenario is that the POLSTform is the only order which will allow emergency medical services to not resuscitate a patient in the event that the patient is unable to express their wishes. But, again, once he’s resuscitated, the patient is coherent and communicative, thus, he has a right to refuse transport to the hospital and a right to refuse medical treatment. His surrogate’s decision-making ability only comes into effect when he is unable to make his own choices and communicate them. That EMS listens to the daughter and say that they have to transfer him unless he signs the document is an assault on his autonomy and his human rights. That she is the one who eventually signs the document (which is clearly an advance directive since it is multiple pages and on white paper; POLSTS in Washington are generally one sheet (two sides) and green) means there is no legal document since she lacks legal authority to sign it. Until she is the legal decision-maker, only the patient, who is coherent and competent, can sign it. If they used the correct form, the POLST, then it would need not only Elliott’s signature, but the attending physician’s as well. Despite the emphasis on documents here, there was no legally executed document when EMS does not transport.
Additionally, while the documents are important, please remember that the conversation is critical. The one lesson this episode does accurately offer is the importance of having honest and truthful conversations with family, friends, and one’s power of attorney for health care.