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If lack of effective communication is the ultimate explanation for the breakdown in the doctor/patient/family relationship, how do we deal with this?
These words were hurled at me as I made rounds on Mr. Morris, an ICU patient who had arrested during hemodialysis and now lay unconscious, connected to a mechanical ventilator. As his hospitalist, I found myself confronted by Mr. Morris's wife and daughters. "How could you allow him to be resuscitated? He never wanted to be kept alive by machines. We want the breathing machine stopped immediately!"
When the patient was admitted, I didn't obtain an advance directive, but assumed that he was a full code because he had had end-stage kidney disease for more than a year and never refused hemodialysis. I explained to the family that, without knowing the patient's wishes, I couldn't stop the ventilator. The pulmonologist managing the ventilator stepped in and said, "Let's first see if he wakes up and then ask him what he wants."
I knew that my first responsibility was to Mr. Morris. I also explained to the family that if Mr. Morris did not regain consciousness, I would then have a neurologist assess brain function in preparation for stopping life support. They were not happy with this decision, but agreed to it.
"I CAN'T DO THAT"
The following day, I made early morning rounds and was greeted by Mr. Morris's nurse, who announced, "Mr. Morris is alert and doesn't want to die." I found the patient awake and alert on the mechanical ventilator.
With the nurse present, I asked Mr. Morris, "Do you want to live, even if it means being on the ventilator?" He nodded "yes" and squeezed my hand. I wrote the order to continue dialysis and documented the witnessed wishes of the patient in the progress notes.
A few hours later, I received a call from Mr. Morris's nurse. "Dr. Green, you'd better come here right away. The family is at the bedside. They refused to allow hemodialysis and want us to shut off the ventilator."
When I arrived, I faced three angry women. One of his daughters said, "I'm an EMT, and I know that after a cardiac arrest there is brain damage and patients can't make rational decisions. Take him off the machine-that's what he really wanted."
"I can't do that," I responded.
"Then we want you off the case," the wife replied. Later that day, I was able to transfer care to another internist.
The following day, Mr. Morris, now weaned off the ventilator, was able to speak and clearly told the chaplain and medical staff that he wanted to live and appreciated all efforts to save his life.
A NEW ERA OF MISTRUST
This real-life scenario, unfortunately, is becoming more typical of the increasing trend of patients and their families questioning medical care, especially in the hospital setting. The key element in any relationship is trust, a precious but fragile concept that is increasingly being threatened in this new era of medicine. The days of Marcus Welby, MD, are gone, replaced by high-tech medical care. The irony is that we can do much more for hospitalized patients now than when I entered the profession more than four decades ago, but at the same time, public expectations may surpass our ability to "cure every patient."
Most patients are now cared for by hospitalists rather than their familiar primary care physicians. In this new therapeutic relationship, a bond of trust needs to be forged rather quickly. However, many patients and their families they still feel quite vulnerable and at the mercy of total strangers when confronted with serious medical issues.