Posted on November 9, 2019 at 1:19 AM
The Good Doctor (Season 3; Episode 6):Risky Choices; The Resident (Season 3; Episode 5): Reporting a drunk pilot; Leaving AMA; New Amsterdam (Season 2: Episode 7): Medical Errors; Chicago Med (Season 5; Episode 7): Subverted capacity; Confidentiality with a military experiment subject; Greys Anatomy (Season 16; Episode 7): When personal feelings interfere with medical judgement;
A pregnant woman has an abdominal tumor and is in the hospital to have it removed. Once in the OR, the surgeons find that the tumor is wrapped around the uterine arteries. The fetus is 23-weeks old, too young to really survive outside the womb. They close her up with the intention of talking to the patient and her husband. The patient and her husband are faced with three choices—(1) wait until the fetus is old enough to be removed and have a better chance of survival, but with the risk of the cancer advancing; (2) remove the fetus knowing it will die and remove the tumor; (3) a riskier surgery to try and remove the tumor and save the pregnancy but with a much higher potential for the patient dying. The patient wants to take the risky road and preserve the fetus: “I couldn’t live with the guilt to kill our baby to save my own life.” Her husband did not want the baby in the first place and says that they can have another child another time, but he can’t replace her. She consents to the riskiest option. During the operation, the artery is nicked and the patient dies. Melendez delivers the baby. In reality, this is handled well. The doctors give a realistic assessment during several conversations with the patient and her family. They all work together to come to a consensus on the plan moving forward. The choice is the patients, though a surgeon would not have to offer an option seen as too risky not agree to perform a surgery that is too risky. Once they have offered it and agreed that they could do it, the patient’s decision determines which of the options to pursue.
Pravesh is torn when his patient has a blood alcohol level of 0.06 and a head injury. The patient is a pilot. If Pravesh informs the FAA he could end his career and patients need to know they are safe when they seek help. Pravesh believes that protecting patients confidentiality is an absolute value. Conrad says Pravesh should make the call to protect lives. Instead, Pravesh gives him information about an AA meeting to which the pilot responds, “I’m not a drunk” and then throws away the pamphlet. The next day, the pilot flies drunk and crashes his plane. In reality, “Confidentiality, considered a fundamental principle of medical ethics, is potentially at odds with public safety when an airplane pilot is experiencing symptoms of mental illness.” The FAA maintains a reporting hotline for just this problem. Despite his good intentions, Pravesh should have reported the pilot.
In another case, a woman with chronic high blood pressure has impaired kidney function, heart damage, and narcolepsy. Pravesh recommends the ICU but the woman says she’s just going to go live her life and wants to leave. Pravesh says that her decision-making must be impaired and wants to place a hold on her. Conrad tells him his choice is based on the pilot and that this case is different—if she does not accept help she endangers only herself, not others. Patients have a right to make bad choices.
A paralyzed patient comes in for surgery. After several decades her back plate (inserted after a cancerous tumor was removed) has shifted. However, once the surgeons operate they learn it wasn’t the cancer that caused the paralysis, it was a surgeon’s bad cut. Max wants to tell the patient immediately after she awakes but Sharpe wants to find out the facts first. The error was covered up by the previous hospital president who said that had he reported the error and gone after the attending surgeon, he would have sued them and won. Instead, he worked to get the surgeon out of the hospital. Max tells the patient the truth and she immediately states that she will sue. In response, the hospital hopes to make her a preemptive settlement offer.
In reality, hospitals and doctors were told to not say “I’m sorry” or admit to errors. But today, there is a movement toward saying one is sorry and taking responsibility for errors. As the board chair says in this episode, the truth usually comes out.
Although not an ethics issue, drawing on the medical humanities, it was interesting to see Frome using reader’s theater to help a veteran suffering with PTSD.
Chicago Med (Season 5; Episode 7): Subverted capacity; Confidentiality with a military experiment subject
Tom is 25 years old and is brought to the ED after he collapsed. He is vomiting blood and has belly pain. He also has teeth implants that look like vampire fangs. Tests show he is in acute liver failure. Kirsten, his girlfriend, comes onto the scene and when Halstead says he wants to run tests, she says that they are leaving. She seems to have influence over him. Halstead asks Tom what he wants (in front of her) and Tom says he wants to go. Halstead says he will need to sign an AMA form first. April Sexton tells her that they will protect her confidentiality. When Kirsten drags Tom out, Charles says they can’t leave and Tom needs to understanding that leaving might kill him. Tom replies that he is already dead—he’s a vampire. Charles says he is putting Tom under a 72-hour hold at which point the girlfriend bites him and then rushes out. Tom does not get very far before he collapses—his skin is burning under the sun. Kirsten disappears and Tom cannot reach her. After refusing medical help, Tom now asks for it. He has Hepatitis C and now, Charles might have been infected as well.
In reality, Halstead should have had the initial conversation with Tom about what to do without Kirsten in the room. As a girlfriend she had no legal right to the medical information nor to make decisions for a competent and capacitated adult. She was clearly a coercive influenced on him. No matter what we think, a patient has a right to make their own decisions, even if those choices imperil their life. But Tom may not have been capacitated as he seemed to be under the influence of Kirsten. Bring in Charles was the right move.
Gina is a soldier arrives in the ED with an infected arm. She lost her arm below the elbow in a Humvee explosion and has a bionic arm. Choi wants to talk to her doctors at Walter Reed hospital when she shares that she is technically AWOL, having left the hospital (where she is a patient?/research subject?) to attend her sister’s wedding. She asks him to not tell the military because she’ll go right back after the wedding. Choi, however, calls her doctor at Walter Reed who is flying out. He says that saving her trumps her request for confidentiality. In a conversation, Sexton accuses Choi of violating her rights. He replies that HIPAA “makes an allowance for cases just like this”. Instead of the doctor, the military police show up with orders to take Gina back Walter Reed. The patient is becoming septic and might not make the 3-hour helicopter flight. Goodwin tells the MPs that they cannot take the patient away without a court order; they have no rights in a civilian hospital. They get the court order. Meanwhile, Choi rushes Gina into surgery to clean out the infection. As soon as she is out, the MPs take custody of her.
In reality, preserving confidentiality is one of the most sacred of a doctor’s obligations. However, it is not an absolute principle, having many acceptable and required breaches. A health care provider should never make a promise that they cannot fulfill, such as Sexton did. Choi’s obligation is not clear here. HIPAA allows one to contact another health care provider to consult on a patient, especially when the consultant is the patient’s primary doctor. There is no obligation to report to the military about their AWOL experimental subject. The question raised in this case is whether a consultation was necessary to treat the patient? We know it was not because the surgery was conducted without it. Sexton accuses Choi of losing perspective to the military and it is possible that he thought as a soldier and not as a doctor in this situation.
A 25-year-old mother comes into the ED after falling down the stairs. She has a bleed in her spleen which needs to be removed. She is also pregnant (8 weeks) and given that she already works two jobs and has trouble finding time to care for her son, she does not want the pregnancy. However, when Shepard suggests that they could call OB to terminate the pregnancy, Hunt says no because her splenic injury comes first. Shepard arranges for the OB to give her a medicated abortion but Hunt is angry because he thought the patient might change her mind. He was allowing his personal feelings toward Shepard interfere with clinically helping his patient.
In a second storyline, Saby is Weber’s niece, and thus Pearce’s cousin. Saby has a large tumor in her heart and needs surgery. Pearce is the very best surgeon, but Saby does not want her to operate because they are family. The question is whether the rule against treating your family applies when they weren’t even aware of each other two hours ago? Against treatment is that there could be resentments and guilt if something went wrong. In favor of treatment is that Pearce is the very best and does not yet have familial feelings toward her cousin. In reality, as Pearce points out, not treating family is an ethical guideline but defining family can be complicated. Saby dies on the table and Pearce becomes upset, losing perspective: How does she tell her family now? Karev tells her that she cries with him in private, and then approaches them as a professional.