Posted on January 19, 2018 at 6:33 PM
by Craig Klugman, Ph.D.
The Good Doctor (Season 1; Episode 12): Life and Death
Continuing a storyline from last week, this episode centered around the conjoined twins who had to be quickly separated. One twin awakes and is doing well except that her heart failure has not improved. If anything, she is getting worse and may not make it through the night. Her sister is unconscious and suspected to be in a nonsentient state. Their mother decides to remove the ventilator from the unconscious sister so that her heart can be transplanted into the surviving one. The sister is not pleased about the death, but she does like the idea that she would be carrying a part of her sister in herself. While watching this scene in the OR, as the doctors prepare to remove the vent, I thought to myself, “The person does not always die when the vent is removed.” Lo and behold, that is exactly what happened. With her heart still failing, the decision is made to re-connect the girls’ circulatory systems to get a push from the unconscious twin’s heart. This works until the unconscious twin wakes up with her full faculties. At the end, the twin with the heart condition dies and the other lives.
Much of the ethical decision-making was very much drawn by the medical needs—With one twin needing a new heart and a perfect match available, the mother readily agreed to the plan. There were moments of compassion in this episode, attempts to have meaningful conversations with the mother. But the decision to transplant the heart, and thus allow one twin to be declared dead, felt rushed (it is only a 44-minute show). After all, even with a GCS of 3, a few hours are probably not sufficient time to make a medical determination of PVS nor is it sufficient time for the mother to make these sorts of decisions. She might have been prepared to lose both children from the separation surgery and thus could have been in this mindset. I also wondered how the staff felt about these actions and the swinging back and forth between which twin would survive. The only instance when the family did not just follow doctor’s orders is when the surviving twin did not want to be disconnected from her dying sister, even if that action would lead to her own death, because she did not want to be alone or to abandon her sibling. If one area received less attention in this episode, it was the effect of separation on the twins: We see this in them recovering in separate rooms and being alone for the first time in their lives. Addressing their psychological needs could have been better attended.
Chicago Med (Season 3; Episode 7): Conflicting Maternal-Baby Needs; DNR; Physician Consent
In the first storyline, a mother who has partially given birth comes to the ER. The infant has been delivered but the placenta is still in place with the umbilical cord attached. When the woman is brought to the treatment room, she pulls the child away, nearly yanking the cord from the baby. The woman is a heroin addict and the baby is now suffering from withdrawal. Dr. Manning suggests that the baby may do better if it is allowed physical touch with the mother. Dr. Charles says that touch might benefit the baby but it could harm his patient since the baby is going to child protective services: Why have her bond with the child only to pull the child away? This represents a conflict in the needs of two patients. Manning believes that a baby’s needs outweigh that of the mother. Charles approaches the mother and she says no initially. Later she is sorry of the pain she caused her baby and agrees to hold him, hoping that she can perhaps help him a little. Later, when CPS comes to take the child, she has bonded and declares her love of the child. The separation is painful and likely not helpful to her recovery. The characters demonstrate the belief that the best decision is the one to help the baby, who is described as “innocent.” Even though all patients should be treated the same, there is a bias toward the baby and against the mother who is blamed for the baby’s health problems.
In a second storyline, a patient is brought in suffering from a degenerative disease. She is having trouble breathing, most likely from pneumonia. The treatment plan includes putting her on a ventilator for a short time while her lungs clear even though there is a risk that she might not come off of the vent. The patient says she understands but does not want to be on a vent, no matter what. The patient explains to Goodwin, unit administrator and also the patient’s boyfriend’s ex-wife, that she has signed a “do not resuscitate order.” Of course, while she may have requested to be DNR, such an order is physician written and does not have a place for a patient’s signature, nor is that needed. Perhaps she meant that she completed an advance directive and the doctor issued a DNR order.
The boyfriend cannot accept the choice. He yells at Dr. Halstead:
“How can you not do anything”
”I explained all her choices”
”But you’re her doctor; tell her what’s best!”
“She made her wishes very clear, there’s nothing else I can do”
“So you’re just going to sit around and let her die?”
However, the patient then has a change of mind—seeing her boyfriend’s inability to accept her dying, she chooses to accept all care including intubation if necessary. Certainly, patients have a right to change their minds and to make their own decisions. It is not unusual for patients to make choices based on what they want or based on what they think family, friends or even their health care providers want. Some dying patients reason that they will not be around anymore, so they will do what the survivors need to make peace with their loss.
When her heart goes into arrhythmia, the paddles are brought over. Her boyfriend says not to do this; it’s not what she wants. The patient agrees with him and says not to do it. The patient dies moments later. As challenging as it can be for dying patients, sometimes it is more difficult for surviving loved ones to comprehend the choices that need to be made and their consequences. A loved one can require time to process that death is imminent and to become familiar with grief. Seeing a code in process can change a person’s mind. Talking about a code is one thing, but actually seeing it is more real and more of an assault that is usually described. The reality often leads family to change their feelings and hopes for their loved ones.
In a third storyline, Rhodes is called to the scene of a collapsing building. A person is trapped and needs to be rescued to treat his injured aorta. The patient does not want to lose his leg but the only way to get the patient to the hospital in time to save him is to remove his leg. The doctors decide to remove the leg. After surgery, the patient is thankful for his life being saved. In a crisis situation, such decisions do need to be made, often quickly. A patient in a state of shock may lack capacity in an emergency, and thus, may need a substitute decision-maker. This situation matches the exception for physician consent—If the patient will likely suffer death or permanent disability without action in two hours or less, then two doctors (one can be the treating physician; one should not be a treating physician) can consent.
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