Invite to comment medical ethics scenario

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Invite to comment medical ethics scenario

The following scenario is intended to illustrate issues surrounding conflict in healthcare and how to best resolve these conflicts. This vignette is fictional. 

Surgeon Bill Toms is awakened at 1 a. M. by the doctor in the Intensive Care Unit, Intensivist Sue Sally.

Intensivist Sue Sally: Bill, thank you for coming in at this hour. The patient in bed 3 was admitted 4 days ago by the medical service for respiratory failure. We intubated him (put a tube thru his mouth into his trachea so the ventilator machine could breath for the patient) and did everything possible to support his respiratory status. It's taking higher and higher pressures on the ventilator to adequately ventilate him and higher levels of PEEP, and we can’t improve his oxygenation. This afternoon, the medical student did a history and physical exam and, in it, he wrote that “the abdomen was exquisitely tender with board-like rigidity”. A few hours later, his supervisor and professor was reviewing the note and became alarmed when he reviewed the history and physical exam and found out that the student had not informed anybody of his finding. When I came on duty, I immediately ordered a CT scan to evaluate his abdomen and then got busy with another patient. It's been crazy here tonight and I've had not had a chance to sit down for a second. When a few hours had passed, and the CT scan was not performed, I called x-ray and they informed me that they had cancelled the study because the nurse had told them the patient was too unstable to go down to the x-ray department. Bill, I know it's late, but I now believe that the respiratory failure is due to intra-abdominal sepsis and I feel really bad about the delay. Thanks for coming in and saving my butt, I hope. After an evaluation Bill comes back to Sue and says the following.

Surgeon Bill Toms (returning from bedside) : Sue, this patient is unstable with the blood pressure falling and the pulse increasing and the respiratory status deteriorating further. He is already edematous, and the urine output has been low for the last couple of hours. His mental status is depressed so it's no longer possible to determine if he has an acute surgical abdomen by physical examination. I do think that the possibility of intra-abdominal sepsis is quite high, and I feel the only chance of survival would be an abdominal operation. This does put me in a difficult position because I'd hate to find myself inside his abdomen and find nothing. I think his chances of surviving an operation are relatively low but greater than his chance of surviving without an operation. Let me go talk to the family.

Intensivist Sue Sally: Thanks Bill. They're in the waiting room and haven't left since the patient was admitted. Bill goes to the waiting room in the addresses the family.

Surgeon Bill Toms: My name is Dr. Bill Toms and I am the surgeon on call.

First son: Surgeon, why do we need a surgeon?

Surgeon Bill Toms: It is becoming increasingly likely that your Dad’s breathing problems are due to an underlying intra-abdominal infection. This is a well-describe phenomenon.

Second Son: Why didn't his doctors pick this up earlier?

Surgeon Bill Toms: It can sometimes be hard to diagnose intra-abdominal infection in the elderly. His doctors have been working very hard to try to save his life. 

First son: What do you expect to find doctor?

Surgeon Bill Toms: I can't tell you exactly what we'll find. It could be dead bowel or a hole in the bowel or even a rotten appendix or we could find nothing. I would hate to find myself inside his abdomen and find nothing especially given how critically ill he is. I can’t promise he will survive the operation or even that I can get him off the table alive.

Daughter: Do you mean you wish to do an exploratory on our father?  Isn't he too sick for that?

Second Son: Can't you just leave him to die in peace?

First son: That's easy for you to say. You haven't seen him in 2 years prior to this illness.

Surgeon Bill Toms: it's very important that the family stick together. No one is omniscient. No one can know for sure exactly what the right thing to do is. Whatever you decide I hope that the relationship among his family members remains strong and enduring. None of you should feel guilt or blame each other. Your Dad is lucky to have family like you who is willing to discuss these hard issues. 

At around 5 a.m., The surgeon, along with the anesthesiologist and several nurses, rolls the patient back to the Intensive Care Unit. This surgeon is ensuring that all the drips are going, and the patient is being ventilated with a PEEP valve Ambu bag. He is paying meticulous attention to this because he knows that transport is one of the most vulnerable times for a patient when drips are inadvertently discontinued when the IV bag is placed on the stretcher and that ventilatory support in the form of PEEP can often be discontinued with disastrous results, even during the short period of transport or in the elevator.  Surgeon Bill Toms  sat down with the family in the waiting room and explained that a fish bone had perforated the distal small bowel, allowing small bowel contents to contaminate the abdominal cavity and cause severe blood stream infection. Dr. Bill Toms said he removed a small segment of bowel encompassing the hole, drained the large volume of bowel contents and pus, and irrigated copiously the abdominal cavity.

Over the course of the next several days everybody is jubilant as the patient continues to improve. The breathing tube is removed, and the patient is sitting in the chair and one by one, the various lines are removed, and preparations are made to send the patient to a regular med-surg floor at the insistence of the head intensivist who's responsible for triaging the beds. At 3 in the morning a code blue is called on the surgical floor when the patient is found to be blue and not breathing in bed. He is quickly intubated and brought back to the Intensive Care Unit. A family meeting is held.

Intensivist Sue Sally tells the family: In my opinion, further treatment is futile and that the patient should be made Comfort Care only.

Surgeon Bill Toms: In my opinion, it is too early to pull the plug.

Intensivist Sue Sally: I am afraid that continued aggressive treatment might keep your Dad alive for a while but there's no hope that he will recover.

Surgeon Bill Toms: There's always room for hope and faith. It is quite true that the odds of your Dad surviving are quite low, but we don't care how a hundred people with his condition will do. We care about how your Dad will do. There are always people who beat the odds. With the advent of robust ethics committees, decisions are no longer irrevocable and that the patient can be made Comfort Care in the future if further interventions seem futile.

A CT scan is performed and a recurrent abscess is identified as the source of multi-system organ failure that caused the patient to be so abruptly returned to the Intensive Care Unit the same night he had been transferred out to a regular surgical floor. However, the radiologist stated that “there's no safe window” to drain the abscess percutaneously. By then, the family had established a close relationship with Surgeon Bill Toms and they agree to give it one more attempt. The recurrent abscess was drained in the operating room by Dr. Toms by opening the old incision and the patient improved on a daily basis and was discharged to home. He never was able to return to work but was able to pursue is hobbies of painting and playing the violin. 

Discussion questions (and please add your own questions and comments)

How was conflict handled? Do you see any good examples or examples where it could have been done better?

What are some other ethical issues such as spending a large amount of money on an elderly man where it might have been better spent for nutrition or better prenatal care for poor people?

When the family implied that care provided by the intensivist team was sub-optimal, how did the surgeon handle it? Should he have blamed someone for the delay?

Did the surgeon adequately explain preoperatively the gravity of the situation to the family? What potential complications are frequent enough to warrant mentioning? Obviously, we just summarized the nature of the informed consent in this vignette.

Those who have a clinical background are welcome to comment on the treatment provided although that is not the main purpose of this scenario and the care was summarized to be accessible to our non-clinical learners, too, and to be a point of departure for discussion.


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