Reflection Part II...
I just finished watching Gray's Anatomy, a pretty worthless show in general, but recently it has had the recurring theme of being able to tell a patient's family that “we did everything we could" and that has given me pause. While at first this seems like a rather heroic and virtuous thing to tell a patient’s family; and this is certainly the way it is in TV medicine, that has not been my experience. Sometimes doing everything we can for a patient is exactly the opposite of what is “right” for the patient.
Last week a 56 year old man was admitted to the GI service with end stage liver disease and recently diagnosed hepatocellular carcinoma. He had gotten his affairs in order; come to terms with his diagnosis; and was being admitted to have an in-dwelling abdominal catheter placed by interventional radiology to mange his malignant ascites at home. Hospice care had already been set up. This was a man who was finished with fighting and simply wanted to go home and die without pain and with as much dignity as his grossly distended abdomen and jaundiced skin would allow.
On the first afternoon of his admission we performed a diagnostic paracentesis to rule out spontaneous bacterial peritonitis before the procedure the following day. My resident gave a short “this is a teaching hospital” intro and then asked if it would be ok if I performed the paracentesis. The patient, after hearing that I had only performed one paracentesis before, politely asked if someone else could do it. He apologized and hoped he hadn’t hurt my feelings; but he’d had a bad prior experience with a paracentesis and preferred someone more experienced to do it. I bantered lightly with him the rest of the time in the room to assure him that it was really all right and as I left the room he had a smile on his face.
His hospital course declined rapidly after that. He became encephalopathic after the catheter placement. He required four point restraints. He became verbally agitated and didn’t recognize his wife in the room with him. On rounds the next morning he was in a “hepatic coma” as his wife put it. When asked what she wanted she tearfully said to take her husband home. The attending offered to put an NG tube in and give him some lactulose before discharge; with the hope that it would improve his mental alertness; at least temporarily. During the NG tube placement bright red blood was aspirated back. Fearing that one of his grade III varices had opened it was decided to give him an upper endoscopy to attempt to stop the bleeding. He passed away before the endoscopy could be performed.
We did everything we could. We did everything we could. We did everything we could. Somehow that just doesn’t make me feel better. There was never going to be a happy ending for this patient. And we knew that. And he knew that. But looking through the lens of hindsight there was a lot we could have not done; we could have not recommended the catheter placement; we could have discharged him immediately following it; we could have spared him the NG tube; and we could have spared his family the decision about an endoscopy.
It’s easy from my standpoint as a student; with no true responsibility for clinical decision making feel that the system betrayed this patient. I am sure that the question of “why didn’t I do something more?” will keep me awake more nights than “I wish I hadn’t done that”. But so far the two patients that I have been involved with who died were both situations where doing nothing might have been the right answer and I can’t help but wonder if the pursuit of having “done everything we could” might not sometimes, albeit hopefully the minority of times, but sometimes drive us to make poorer decisions.
Last week a 56 year old man was admitted to the GI service with end stage liver disease and recently diagnosed hepatocellular carcinoma. He had gotten his affairs in order; come to terms with his diagnosis; and was being admitted to have an in-dwelling abdominal catheter placed by interventional radiology to mange his malignant ascites at home. Hospice care had already been set up. This was a man who was finished with fighting and simply wanted to go home and die without pain and with as much dignity as his grossly distended abdomen and jaundiced skin would allow.
On the first afternoon of his admission we performed a diagnostic paracentesis to rule out spontaneous bacterial peritonitis before the procedure the following day. My resident gave a short “this is a teaching hospital” intro and then asked if it would be ok if I performed the paracentesis. The patient, after hearing that I had only performed one paracentesis before, politely asked if someone else could do it. He apologized and hoped he hadn’t hurt my feelings; but he’d had a bad prior experience with a paracentesis and preferred someone more experienced to do it. I bantered lightly with him the rest of the time in the room to assure him that it was really all right and as I left the room he had a smile on his face.
His hospital course declined rapidly after that. He became encephalopathic after the catheter placement. He required four point restraints. He became verbally agitated and didn’t recognize his wife in the room with him. On rounds the next morning he was in a “hepatic coma” as his wife put it. When asked what she wanted she tearfully said to take her husband home. The attending offered to put an NG tube in and give him some lactulose before discharge; with the hope that it would improve his mental alertness; at least temporarily. During the NG tube placement bright red blood was aspirated back. Fearing that one of his grade III varices had opened it was decided to give him an upper endoscopy to attempt to stop the bleeding. He passed away before the endoscopy could be performed.
We did everything we could. We did everything we could. We did everything we could. Somehow that just doesn’t make me feel better. There was never going to be a happy ending for this patient. And we knew that. And he knew that. But looking through the lens of hindsight there was a lot we could have not done; we could have not recommended the catheter placement; we could have discharged him immediately following it; we could have spared him the NG tube; and we could have spared his family the decision about an endoscopy.
It’s easy from my standpoint as a student; with no true responsibility for clinical decision making feel that the system betrayed this patient. I am sure that the question of “why didn’t I do something more?” will keep me awake more nights than “I wish I hadn’t done that”. But so far the two patients that I have been involved with who died were both situations where doing nothing might have been the right answer and I can’t help but wonder if the pursuit of having “done everything we could” might not sometimes, albeit hopefully the minority of times, but sometimes drive us to make poorer decisions.