Ethics on Call: A Case Study on my Weekend in Hellllllooooo
Part of my Family Practice Residency training involves “house call.” During this, residents are not actually in-house (we used to be); we cover any patient under a family doctor, rehab, psych, palliative, and ‘overflow’ (long-term care), as well as most surgical/uro/gyne/ortho patients. We don’t cover peds, obs, or hospitalist patients and we don’t do admissions. Nurses call us from the wards about status changes in the patients (“he’s agitated,” “he is short of breath”) as well as for medication orders.
Some nights are busy and some aren’t. I’m the resident on call this weekend and it has been steady. Even though it isn’t crazy busy, it is challenging.
I have had a significant number of calls where I think I know the most appropriate medical action, but I don’t really know the correct action from ethical and medico-legal standpoints. I have tried to change some details to enhance confidentiality, however, the other docs involved might recognize the patients in question.
Here are a few examples, just from one day(!):
Patient: Lady with liver cancer, cirrhosis. Not palliative yet.
Nurse’s Call: “she’s just not feeling that well” “maybe some difficulty breathing”
Assessment: Ascites (lots of fluid build up in the belly; the liver isn’t working, isn’t making the protein that is needed to hold fluid inside the blood stream, fluid leaks out into belly/legs/arms/etc.) Fluid in belly pushes lungs up, makes it hard to breath. Needs fluid drained from belly.
Plan: Internist on call very helpful, make arrangements to improve clinical situation prior to procedure on a future day. Surprised that the internist volunteered to do a procedure on a day when they aren’t even on call. Future day comes, they are busy understandably, but discussed with new internist on call. Also very helpful. Suggests some changes to better optimize this woman and will do the drainage tomorrow.
Me Grumbling: Medically this procedure is required, can wait, but I still feel a bit uneasy. Have done it before. Was tempted to just do it on my own. Have done it before, it’s not that hard. But, can be bad complications. I think residents in the big city would just go for it. I don’t want to hurt anyone. Don’t want to get sued. Decide the plan is the best possible. Move along.
Solution: Continue as planned. Personally, must get more experience in ultrasound and procedures so I can just do this whenever I think I need to. Relax.
Patient: Little old lady >90 in for urosepsis.
Nurse’s Call: Abnormal vitals. Needs some treatment. Also “can you get a code status on her?”
Assessment: Some medical stuff, no biggie. DNR status unknown.
Plan: Handled medical stuff by phone. Hemmed and hawed about assessing the DNR thing (see below).
Me Grumbling: Residents get asked soooooooo often to establish “code status” on patients. The team needs to know whether to provide CPR to their patient if their heart or breathing should stop. It’s a reasonable request by the nurses however it is a really big can of worms.
If a patient has a DNR form, a copy of it in their purse, and a family member standing beside them who says “yah, mum wants no CPR,” plus you have known them for 10 years and you have had this discussion in the office, then it’s pretty clear what to do. however, if you are the resident, seeing a patient for the first time at 23:00 and they are delirious and their family can’t be reached, and they are old and sick or old and not sick or . . . whatever. It’s usually pretty muddy and can be difficult to make this call.
Doctors can override patient’s requests eg. if they feel resuscitation would be futile, and this does happen [usually after a code is called]. However, when you are only tasked with recording the patient’s status (at that time, preference) on the chart, it is not easy to make a quick judgement call. And it is not really fair to ask me to liaise with family members with whom I have no relationship about end-of-life considerations. They start asking questions like “how is mum doing,” “did we get a bed at the Rehab unit?” etc. that I just can’t answer because I’m not that patient’s doctor. Also, they may have a differing opinion than the patient, who may or may not be delirious (aka disoriented, confused) at the time. It would be very easy to write the wrong thing in the chart. This might not have major practical consequences (anyone who looks like they are long-gone probably will have CPR declared futile) but in the odd case it might. Plus, it may be in the record erroneously and perpetuated forward without ever being reassessed.
Solution: Make it mandatory for every patient to have recorded “DNR” or “Full Code” on their chart. If there is no documentation either way, the patient cannot be admitted.
Patient: Metastatic breast cancer, falls (with multiple fractures) and hit head. Now confused (though on sedating medication) and has racoon eyes.
Nurse’s Call: “Can we do a head CT? I called the doctor covering for the clinic this patient belongs to. That GP says he doesn’t know this patient, hasn’t heard anything about them, and so he doesn’t want to get involved.”
Assessment: Over the phone, sounds appropriate, kind radiologist agrees to help and do the scan. I come in and see this person. Decreased consciousness, looks like they just smacked their face really good. No major neuro red flags.
Plan: Head CT to rule out bad stuff like bleeding in the brain. Not that this patient would be a great surgical (eg. burr hole) candidate, but it might slightly alter care and might help the family (and patient) understand about prognosis etc.
Also, do a little dance in the elevator when the scan comes back as no brain bleed! Hurray!
Me Grumbling: Technically the nurse could have called me before the GP. However, knowing that the Most Responsible Physician (MRP) is not at all interested in and maybe not capable of taking responsibility, I feel a bit hung out to dry. Even though I’ve arranged the scan, I’m not sure I can handle all the follow-up it might entail. Plus, it would be really nice to know someone is following up. I do not know how aggressive to be with this patient since they are somewhere between live a good while and die tomorrow – kind of a broad spectrum. Mostly, I feel bad for the nurses. What do they do when there isn’t a resident and the MRP can’t help? Bad mojo!
Solution: When I am allll growwwweeed uppppp, I will do my best to make sure there is good handover of admitted patients to the MRP for that patient (if I happen to be working in the ER). Also, if the MRP for the patient switches, whether I’m the giving or the receiving, I’ll talk with my colleague (GP to GP handover). The other thing is that the system needs to find a way to document when people don’t answer their pages, when they refuse to provide care, etc. because it could be dangerous! (Nurses chart this, but it seems to go into the black hole of medical records, and nothing changes). There are probably a lot of good reasons for refusing care [like me in Case 2, not wanting to get a Code Status on someone] and I doubt that the doctor refusing is the real origin of the problem in most cases.
Patient: young guy, was on a drug that wrecked his bone marrow
Nurse’s Call: “I’m supposed to transfuse blood but the consent isn’t signed. Can you get the consent? By the way, he is delirious and keeps falling asleep when I talk to him.”
Assessment: Hemoglobin (blood count) of 80. 80 is okay, ideally would be 120+. We only transfuse blood into people when they are having symptoms of anemia, getting ready for surgery, or losing blood. This guy is too sleepy/confused to tell me if he’s having symptoms, won’t be having surgery, and isn’t actively bleeding. Don’t know who ordered the blood or why.
Plan: Definitely can’t get informed consent. Am allowed to do a physician override in the case where I really believe he needs blood [and is not a JW], but I’m not sure that he does. I am not sure this transfusion is indicated although maybe it is. Advise RN to track down original person who ordered this. If no success finding them, call the patient’s MRP who [see above!] should have gotten a call with handover info from the ER doc.
Me Grumbling: So I kind of passed-the-buck here because I was totally uncomfortable with the situation. When I assessed this patient, the chart was actually “lost” in another part of the hospital where the patient came from, so I didn’t know much about him at all. Later, the request for the consent issue came up.
Solution: Whoever orders blood should also do the consent. In this case, it was probably just an accidental oversight – and unfortunately the level of consciousness of the patient changed since the transfusion had been recommended, such that he was unable to verify a consent. I’m sure I’m guilty of forgetting to have a patient to sign a form before and there are even times where I didn’t discuss all the major benefits and possible bad outcomes. If it is an issue of the physician not having enough time, maybe we could have printed out cards with risks, benefits, alternatives, etc. to give to people to read; the patient’s understanding of this information could then be checked by a nurse or doctor and consent obtained. The risks and benefits are pretty well the same for the blood products in all people in all indications. There may be issues with literacy or special circumstances that warrant full discussion with an MD (and other therapies and interventions should involve informed consent too).
Anyway, it is now 20 minutes beyond when I’m on call. Time to hang up the pager, hit the hay, and stop worrying!