Posted on May 17, 2019 at 10:58 AM
by Craig Klugman, Ph.D.
Max Goodwin is at home resting from his chemotherapy after stepping down temporarily from his medical director position. Dr. Bloom knocks on the door to talk to him and finds Max covered in blood, his wife’s. Georgia is fairly far along in her pregnancy and has experienced previa: She is bleeding out. Max calls for an ambulance which seems to be impossibly far away and unable to get there. Before Georgia drifts into unconsciousness (from the fentanyl patches Max gave her), she makes him promise to save their child, no matter what. Using household implements, Bloom is able to suture the blood vessel, though Georgia has lost a lot of blood. She begins having contractions which are a threat to the fetus’s life. The ambulance will not arrive in time with blood. Bloom can save the baby, which will kill Georgia, or the mother, but not both. Max cannot decide despite his wife’s wishes. Bloom tells him that he can’t make the decision because it will haunt him. Instead, she asks him to let her decide. Bloom delivers the baby, born alive and healthy. We next see the paramedics bring in blood, paddle shocking Georgia, and Bloom yelling, “She has a pulse”. Georgia wakes up and meets her child in the ambulance. All is going well until they are struck by another ambulance and the season finale cliffhanger is who lives and who dies? Max and the baby do. But for everyone else, tune in next season.
When Bloom makes the choice, she is not acting as his doctor, but rather as his friend. A doctor can offer advice, but cannot make a choice like this for the decision-maker. This is an impossible situation because there is no right or wrong answer. There is only making a choice and then learning to live with the consequences.
Desiree Parker is a pregnant woman who arrives at the ED with her husband. She is at 20-weeks’ gestation but with a large belly, the result of cancer. A CT scan shows that the cancer has metastasized to her brain, the results of her refusing treatment after learning of her diagnosis at 3-months gestation. The next step is a craniotomy which requires general anesthesia which poses a small risk to the fetus. Desiree refuses the surgery, but when she falls unconscious, her husband tells them to do the surgery: “I’m her health surrogate decision maker. I say do it, now.” Given the patient’s refusal of treatment before she lost consciousness, the question is whether that refusal holds or can the husband override? Dr. Charles states that he had been unable to assess the patient’s capacity but her brain tumor could have affected decision-making. Manning states that the patient was consistent in her refusal. Desiree has an advance directive which names her husband as the decision-maker. Manning feels that the husband is ignoring the patient’s wishes. Goodwin rules that the AD stands; the husband gets to make decisions while the patient is unconscious (why the administrator makes this decision instead of calling for an ethics consult can only be because of a lowered actor budget). The husband later approaches Charles and seems to be second-guessing his decision for surgery. Charles explains that Desiree is unlikely to ever wake up, but that with drugs and a ventilator they could control the swelling and hopefully keep her body functioning until the fetus develops enough to be removed (e.g. turn his wife into an incubator). The husband says he knows what she would want him to do (incubator), but that idea “terrifies” him. Eventually he changes his decision, choosing to follow his wife’s wishes even though this will end her life.
The job of a medical power of attorney in Illinois (where this show claims to take place) is to make the decision that the patient would have wanted. A designated decision-maker, in Illinois, is not the same as a default surrogate (someone who makes decisions based on a default hierarchy in the law, but who is not appointed by the patient). One question I have is what does the advance directive say beyond appointing a decision-maker? Does the MPOA choose DNR and comfort care only? Full aggressive care? Something in between? Does the statement in the AD match what the patient said she wanted (which could have been affected by her brain tumor; her refusing any treatment at diagnosis suggests a long-standing value)? Are we looking at one patient (a pregnant woman) or two patients (a woman and a fetus—the answer legally can depend on the state. In Illinois, the answer is one patient). What are the chances that the fetus would be affected by the general anesthesia? According to the literature, second trimester surgery is less risky than earlier in the pregnancy; the risk is compromising oxygen flow to the fetus as well as premature labor. There is not necessarily a “right” decision in this case. Choosing to follow the letter of his wife’s wishes seems to follow her autonomy, though whether that autonomous act was done with capacity is in question. His reasoning for the decision is rational. But, choosing to save his wife and doing everything possible to preserve the fetus (modifying anesthesia) is also a fine choice as it errs on the side of life. If somehow the wife survived, though, and the fetus did not, she would be unlikely to ever forgive. He has an impossible choice, both ethically defensible, and no clear right answer. Since there is no evidence to support doubting the wife’s capacity to consent, the better answer is to err on the side of honoring her autonomy.