Posted on April 6, 2019 at 2:54 AM
by Craig Klugman, Ph.D.
Jump to The Resident (Season 2; Episode 18): Durable Power of Attorney; Lying; Jump to The Resident (Season 2; Episode 19): Death and “Doing too much; Jump to Chicago Med (Season 4; Episode 17): Personal feelings; Jump to Chicago Med (Season 4; Episode 18): Abortion with a minor; leaving a surgery
An 18-year-old female Olympic-hopeful has shortness of breath and calf pain. Alex and Conrad are jointly treating her. She needs to be on a blood thinner but that means she has to stop training for several months. The result is that she’ll miss the trials for the Olympics and she’s already old for her sport. Alec tells the patient that his sister had to choose between blood thinners and a basketball career. She chose the career and died. Conrad calls him out for lying to the patient, saying that you take the time to explain to a patient rather than finding an unethical shortcut. Later, pelvic pain leads to an MRI and biopsy that reveals the patient lacks a uterus, but does have testicular cancer. However, because of the testicular tissue, she may have had above normal testosterone levels, giving her an advantage in competition. She chooses to have the testicles removed. Conrad calls out Alec that it is wrong to lie to a patient, especially when it is for the doctor’s convenience (rather than the patient’s benefit). Conrad quickly forgives Alec, but he should not.
In a second storyline, Voss’s first husband arrives with shoulder and back pain. Quickly, we learn that he has an aortic aneurysm that leads to other problems. He ends up in a medically induced coma to save his life. He needs surgery but the risks of operating are almost as high as the risk of not operating. The patient has a “power of attorney” where he listed Voss as his decision-maker. We glimpse an electronic medical record where we see his document, “Power of attorney.” The problem, of course, is that a power of attorney is different than a medical power of attorney. A power of attorney no longer applies when a person becomes incapacitated. The document we see is invalid at the time that it is needed. In Georgia, where this show claims to take place, a “Durable Power of Attorney for Health Care” (DPOA) is someone who makes a patient’s decisions when they are no longer able to make choices. Also, even if the document had been a DPOA created when they were married, then it is becomes invalid upon their divorce (unless there is a note attached saying that the person should still be the DPOA). A further complication in this case is that Voss works for the hospital where her first husband is a patient; that fact makes her ineligible to be a proxy decision-maker for this patient. Under Georgia statute, the decision maker should be an adult child (we are told there are 3) followed by the patient’s parent.
Another problem here is that the patient has not had a conversation about his wishes with a DPOA (or even a POA or with his ex-wife). The proxy’s role is to make the decision that the patient would have made. But without having such conversations, it’s impossible to make a substituted judgement. Voss asks Bell how she decides and he says she should trust her instincts. She responds that he would not have wanted to wait, and consents to the surgery.
Donna is an elderly woman who spent 25 years working in hospice. She begins the episode by asking “Shall we talk about how I’m going to die”? Her pain is bad and she refuses pain meds to keep a clear mind. She has signed a DNR order and wants to be comfortable (no needle sticks). She has planned to be in hospice, surrounded by friends and gospel music. She has one more item on her bucket list, to see an old love. Her pain increases and her mental status becomes altered: She has a strangulated hernia. Surgery could fix it, but that goes against her written advance directive wishes. Nevins says that meeting her love is important so they should do the surgery. Conrad says the health care proxy should make the decision, but the phones are down. Conrad says “If there’s no proxy than I have to decide.” He decides to give her pain meds and make her comfortable. Nevins goes above Conrad to Bell, to convince him to override Conrad. Bell’s question to Nevins is whether the patient has insurance (she does) at which point he agrees to the surgery, which turns out to be complicated. Nevins asks Bell to stop when he discovers the bowel is dead and requires a resection. Nevins says that Donna needs to be able to control how she dies. Bell says that he won’t let the patient die in his OR and she is leaving his table alive. Donna goes into cardiac arrest on the table and Bell begins CPR against Donna’s wishes. As Conrad points out, a death will go on Bell’s stats, so once the surgery begins, he has to keep going to protect his own record. Donna pushes through and awakens. Nevins says that she was afraid she did the wrong thing, and the patient says that Nevins did. When her first love shows up, Donna tells him, “Go to hell” and laughs.
This plot turn is interesting since Georgia law specifically says, “A physician or health care provider directly involved in the care of the declarant may not serve as health care agent.” In Georgia, if the proxy is unavailable, the hospital should try to reach the patient’s parent (deceased in this case), spouse (none in this case), adult child (none in this case), sibling (unknown). In this case, the patient is unrepresented. The decision is urgent (in a few hours) but not emergent (right now). Thus, the decision should be sent to an ethics committee or on call ethicist. However, there is no ethical or legal option for Bell’s step–a hospital CEO as the surrogate decision-maker. As an analogy, we can look at Georgia’s rules on discontinuing CPR outside of a specific patient statement—this requires the concurrence of two physicians andsupport of an ethics committee. But if the patient is in hospice (as clearly this patient is), then CPR is presumed not wanted. Thus, Conrad is making the right choice, but he is not the one who is making them—he is carrying out the patient’s already stated wishes. There is a challenge of knowing when to stop and when to fix; when to say enough and when to go a little more to gain more life. This patient left no doubt what she wanted—control at the end of life and no medical interventions (not even an injection). The surgery is nothing less than a battery and a paternalistic assault against her autonomy.
The best lesson comes from Pravesh who talks with a medical student who admits he never thought of death as part of medicine. Pravesh tells him that he will see a lot of death and that “death is a natural part of life.”
Ben is a young man with cystic fibrosis who comes in with a high temp. He’s been in and out of the hospital three times in the last month with infections and is high priority for a lung transplant. Lungs become available and are on their way when Ben develops complications. A chest tube is called for but he’s had so many, the scar tissue may prevent him from being able to get the transplant. He’s crashing too fast and a chest tube is inserted. Latham finds that his lungs have fused to his chest wall from the scarring and a transplant isn’t possible. Without the transplant, Ben will die. He’s septic and has a DNR. In a twist, Ben’s girlfriend is next on the list to get the lungs—his death will save her life.
Sandy Glenn passed out in her home from poor nutrition. She has relapsing/remitting multiple sclerosis. After trying all approved therapies and trying to get into a clinical trial (unsuccessfully), the patient has infected herself with a tapeworm to reset her immune system and treat her disease (this is based on published theory). The patient leaves AMA but Charles stops her by putting her on a psych hold. He believes the patient doesn’t understand the risk of having a tapeworm (and he’s acting out because his ex-wife, who is undergoing chemo, pushed him away). After speaking with Goodwin, he releases the hold. The moral of this story is leave home problems at home and don’t take them out on your patients. Additionally, there is a long tradition of self experimentation which is not advised, but as long as someone knows what they are doing, no one can stop them.
In a third storyline, a car crashes through an ED window and pins Don, a health care worker, underneath. His femoral artery is torn and he’s bleeding out. Sexton crawls underneath the car and pinches off the artery. Don worsens and Choi holds off moving the car until the right equipment arrives. Is his decision based on what is best for Don, his patient, or for Sexton, his ex-girlfriend? He may have waited too long to save Don. Goodwin tells him that she’s reviewed the records and talked with people on scene, and says, it’s a tough call when you have people’s lives in your hands. There’s no clear right answer in this case, but his obligation was to the patient first. Did his previous relationship effect his decision-making? We are led to believe that it has.
Jenny Simpson is 17 and arrives in the ED with her parents. She presents with abdominal pain. The patient refuses an ultrasound at first and then relents. Manning and Choi suspect that she’s hiding a pregnancy and believe that she won’t be able to hide that from her parents. Her blood work indicates pregnancy. Manning and Choi speak with her when her parents are out of the room. Being from Indiana, she went online and bought an abortion pill but was unable to get the second dose. Jenny doesn’t want her parents to know and Choi tries to tell her that they’ll be more understanding than she thinks. Manning says they will give her the second pill. Choi tells Manning that since Jenny is a minor, they need parental consent for the medication. Manning says that the parents don’t need to know. When the parents walk by, Manning tells them they are still running tests. Choi accuses Manning of lying and she states that she is honoring her patient’s wishes. Choi believes they have a right to know, but Manning holds her ground.
During a conversation with Goodwin, Manning explains that because Jenny is from Indiana she needed parental consent for an abortion. Being afraid to talk to her parents, she turned to the internet for “her generation’s version of a back alley abortion.” Since Jenny is now in Illinois and still has a positive pregnancy test, she “is emancipated.” (Under Illinois law, a minor has the right to make her own reproductive decisions including an abortion. However, in Illinois, there is a parental notification law the parents should be told (unless the patient opts for the judicial bypass option)). In this case, however, the law is not clear since the patient initiated the abortion on her own in another state, but she did not expel the embryonic tissue because she did not take the second pill—is the second pill an abortion? Is it reproductive medical treatment? Goodwin is going to check with legal.
When the patient starts bleeding, Choi starts to tell the parents until Manning cuts him off. He then requests their consent for a transfusion. Goodwin comes back with information that legal is concerned about liability and is requiring parental consent for any further procedures. Manning performs an intravaginal ultrasound which shows some tissue remains. Jenny needs a D&C and that will require parental permission. Jenny is afraid and doesn’t want them to know. Manning says, “They love you and they would never want to lose you.” Jenny wants to tell her mom, and only her mom (In Illinois, only one parent needs to be notified of an abortion, or give consent for a medical procedure). Mom is upset that the doctors did not tell her. Mom also comes out saying that what Jenny did was wrong; that it was murder. She also does not want the father to know. Choi asks her if the father has a right to know and mom says no, because he’s not the biological father and she never told him that.
Rhodes is in the middle of a surgery on a VIP patient when he receives a phone call that causes him to rush out of the surgery. His ex-girlfriend (and Charles’s daughter) has been kidnapped and Rhodes is supposed to meet them to get their demands. Clearly, this is an overdramatized situation, but in reality surgeons are called out of surgeries for many reasons. Rhodes made sure that there was a competent surgeon who could finish the procedure even if it was not he who personally completed it. Ideally, patients should know who is doing their surgery, but situations can change. As long as the patient is not endangered and they are left in the hands of a competent surgeon, there should not be an issue. The patient does not need to be told about the change unless there is a complication or unless they ask. This storyline wraps up with the whole situation being a scam and the ex/daughter was never in danger. We are led to believe that Bekker (who finished the surgery) may have orchestrated the whole thing.
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