Sunday, May 19, 2013

Common Sense


Has common sense been lost forever from the world healthcare? I ask this question because of a recent call I received about a patient of mine who had arrived in the ER hypotensive, hypoxic and fast approaching death. The ER doctor called me suspecting she had an intestinal obstruction. Then he told me her name: Linda X.
The name immediately resonated with me because I knew her well, having operated on her twice in the last year. I had first seen her when she was admitted with abdominal pain about a year before. She had a history of moderately severe COPD and was intermittently on home oxygen. Workup at that time revealed a mass in the head of the pancreas. She was not jaundiced nor obstructed at that time. CT Scan suggested her tumor was resectable, therefore her underlying medical condition was optimized and then she underwent surgery. At operation she was found to have adenocarcinoma of the pancreas with involvement of the superior mesenteric artery and vein, making the tumor unresectable. After surgery she was referred to the Medical Oncologist who gave her chemotherapy for 6 courses and then referred back to me to be reexplored. Although my past experience suggested that her tumor still would not be resectable, a second look represented her only chance for cure. She opted to proceed with surgery. The findings at the second operation were almost identical to the first. The tumor had not increased significantly in size, but also had not shrunk, a finding which was not very surprising.
It was Linda who was in the ER now, about 8 months after her second exploration. In addition to the suspected intestinal obstruction she also was found to have a pulmonary embolus, pneumonia, acute renal failure and was profoundly acidotic. The ER physician asked me when I would be taking her to surgery. My polite answer was “never;” I thought I heard a gasp on the other end of the phone.
“But, she’s obstructed and may have dead bowel, and she’s not a DNR,” he stated.
“She has unresectable pancreatic cancer which has not responded to any other treatment. What am I going to do? Keep her alive to suffer for an extra few days. I think you should just keep her comfortable and let her go peacefully,” was my reply.
He hung up, but did follow my advice, which was a bit of a surprise, someone actually thinking about the patient’s best interests.
I was involved with a similar patient many years ago, when I was Chief Resident in surgery. Allen came to our clinic with a carcinoma of the rectum. The diagnosis had been confirmed by colonoscopy and biopsy. He was having intermittent rectal bleeding and tenesmus. He did have moderately severe COPD, but his symptoms warranted surgery. He was further evaluated with a CT Scan of his abdomen and pelvis which revealed liver metastases. Still, surgery for palliation was indicated; besides, abdominoperineal resection was a good case for a Chief Resident. This was in the days before rectal cancers were treated with preoperative chemo/XRT. Allen was scheduled for surgery, but a few days before he was to undergo the procedure he was admitted to my service with shortness of breath. His chest X-ray revealed probable lymphangitic spread of his cancer, something that had not been apparent a few days earlier on his CT scan.
I sat and talked with him after the all the workup had been completed. I explained that he had a very aggressive cancer and that, even with chemotherapy, surgery and radiation, he had a very limited life expectancy. I asked him what treatment he wanted, explaining all the options from aggressive chemo to hospice. He asked for time to consider the options and, before he could make a decision, he suffered a cardiopulmonary arrest. At that moment, I had just finished a surgery and was in the PACU when I heard the all too familiar “Code Blue” for room 623, Allen’s room. I raced up the stairs and found the medical team doing a full resuscitation, about to intubate him. I pulled the senior medical resident aside and politely asked him to stop, explaining Allen’s condition.
“But there’s no DNR on the chart,” he protested.
“I know, but with his cancer his chance for long term survival is just about zero and all you will do is make him suffer,” I answered.
He finally agreed and Al was allowed to pass away. (sounds better than “die”).
Such scenarios occur on a regular basis. We physicians expend a great deal of time, effort and money caring for patients with hopeless conditions. I am frequently called to see elderly, bedridden patients with advanced Alzheimer’s for debridement of necrotic sacral or hip or ischial wounds. Often they have been ignored by their families until they have become too ill to stay in the Nursing Home and are sent to the hospital. Out of guilt or misplaced sense of duty, family members often want “everything done” even if it means making Grandma suffer and while doing nothing to improve quality of life. In such cases I will usually explain that the chances of the wounds healing are poor, but it usually falls to deaf ears. Most often, if the family insists, I go ahead with the procedure as it is low risk and does provide some small benefit.
Statistics show that a large portion of the health care dollar is spent on patients in the last six months or year of their life. In my book about surgery, “Behind the Mask”, I state that the problem with this statement is that physicians very often do not know which octogenarian with a perforated colon is going to walk out of the hospital completely recovered or succumb to overwhelming sepsis. However, in cases like Linda’s or Allen’s, the treating physicians should know that their prognosis is hopeless and that they should be kept comfortable and allowed to die with dignity.
Where does all this lead? The practice of medicine demands that physicians make medical decisions and judgments on a regular basis. It is our duty to explain options, risks and benefits to our patients and their families. Very often such discussions involve treatment options for life threatening illness and it is best that doctor, patient and family reach a decision together and that such decision be clearly documented. Ultimately it is the competent patient’s choice, not the doctor’s or patient’s family.
But, in a situation where the patient is unable to make the decision and an immediate decision is needed sometimes a doctor must exercise common sense and do what is right. This does not mean care should be withdrawn; rather it means that extraordinary measures which will only prolong suffering should not be instituted. Does this mean the doctor is playing “god?” I don’t think so. We physicians spend four years in medical school and even more years afterwards in residency. We should understand the disease processes we treat and should be properly equipped to exercise judgment in cases like the ones cited above. A little bit of common sense in such situations serves our patients and their families well.