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A Letter from a CHM Alum--A Case from Practice

We were both delighted and saddened to receive this letter from a CHM graduate who took the ethics module within the last decade and who now practices in another state. For confidentiality purposes because an actual case is described, we have concealed the graduate's name, exact date of graduation, city, and the name of the small group preceptor to which the letter was addressed. Since the writer wanted this message to be transmitted to students now in the module, we are posting the contents on the course website.

 

September 7, 2004

 

Dear Dr. XXX,

 

My partner and I are affiliated with a small local hospital. We are two of three internists. We are frequently consulted for difficult cases by the family practice docs in town. I have a "real life" story for you to share with the students. After this happened, I said to my partner, "I have to write to Dr. XXX, who taught me what to do in situations like this." So, Dr. XXX, for as much mumbling and grumbling the students do about the amount of ethics we are being taught, I hope you know that it sinks in, and the information is essential to practice. This stuff actually does happen in real life and the decisions are extremely difficult. You may wish to tell the students that I just took the internal medicine boards, and there were at least ten ethics-type questions.

The case I wanted to tell you about was a consult I received for an ICU patient. The woman was 65 years old and had pneumonia with hypoxia, oxygen sats only 85% on CPAP with 100% oxygen. When I went to see the patient, I found a woman in profound sepsis with hypotension, hemoglobin 6.8, and likely in DIC. I explained to the family the grave situation, recommended intubation, ventilation, and blood transfusion. The family insisted I do absolutely everything possible to save their mother's Iife.

As I was placing the central line in the patient, she awoke and seemed fairly coherent. I explained to her that I had discussed her situation with her family and they said it was okay for a tube in the throat, a breathing machine, and a blood transfusion to save her life. The patient shook her head,"no." When I looked at the daughter, she said, "Well mom did say she never wanted to be on a ventilator, no matter what." I said, okay, no ventilator.

When the blood came to the ICU, the nurse and I were confirming the identity of the blood, the type, etc, and we were actually attaching the tubing when the patient ripped off her CPAP mask and said, "No blood." I said, "This is the blood we've been waiting for, you need this to help you." The woman actually sat up in bed and said, "No blood." She was gasping for air and whispered, "I'm a Witness."

I looked at the nurse, who didn't know the patient was a Jehovah's Witness. She went to check the chart. I looked at the daughter and son who were both standing at the bedside and said, "Your mother is a Jehovah's Witness?" And the daughter burst into tears and said, "Oh I think it's stupid. Give her the blood if she needs it." The son said, “Give her the blood." The nurse returned with the chart and, sure enough, the advanced directives were clearly on the chart for no blood or blood products. I told the family I could not give the blood. We would use synthetic volume expanders instead (like Hetastartch).

At this very moment I was thinking to myself, "You've GOT to be kidding. This is one of those ethics cases you hear about as a medical student and say, `that would never happen' the situation is so ridiculous." And there I was living it.

Needless to say, the woman died. She only lived about eight more hours. The family was sad and crying, but at the time, they seemed to understand my ethical obligation to my patient. Apparently they forgot about that, because I received my notice that I was being sued for withholding life saving measures. I have no idea how the case will turn out. I am hopeful that I responded to the wishes of my patient and that should be enough. Her death may not have been prevented even with intubation, ventilation, and blood transfusion; she was profoundly ill. However, the family is extremely angry with me. They have all transferred their charts from my office to different doctors' offices.

I felt pretty terrible about the patient's death. I was extremely aggressive with volume expanders and blood pressure medicines. I felt I did the best I could have given the dire situation I was presented with. However, all the family remembered was that I told them what their mother needed to save her life, and then told them I couldn't do it. I was actually pretty mad at the family because they withheld information they knew about their mother's wishes, hoping I would do the things they wanted for their mother. It's tough. The patient is to whom I am obligated, but the family is who I have to face everyday.

Thanks for all your effort in teaching students about this stuff. Remind them how much they need this information. Tell them I said so!

 

Sincerely Yours,

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