Wednesday, March 21, 2012

Being Accused of Murder




“You would have been hung in World War II for doing what you are doing now,” I was told by a prominent member of a surgical service at my hospital when I suggested we stop the intravenous hydration.

The patient had suffered a devastating stroke. Her advance directive (notarized no less) stated that she did not want any artificial means of life support specifically mentioning artificial nutrition or hydration. Further, she also clearly stated that she would never want to be in a nursing home. The palliative care service on which I was attending was consulted to assist in removing the ventilator. We did. The next day, she was breathing on her own, showing no signs of decline, and even opening her eyes so the prominent doctor on this surgical service started intravenous hydration. I was immediately uncomfortable with this value discordant move so I called her sister who was listed as the medical power of attorney to clarify what the patient meant in her advance directive (because apparently it wasn’t clear enough for the primary team). She told me a story about her sister hunting deer outside her house and dragging them down the mountain all by herself at the age of 70. She used this story to explain how her sister would never want to be in a nursing home and if the best that she could hope for after this stroke, then she would definitely rather be dead. She agreed that we should stop the hydration. There was no ambiguity here.

I called this prominent member of this surgical service and explained what the MDPOA had told me about stopping the hydration. That’s when he said, “You would have been hung in World War II for doing what you are doing now.” It is a good thing that we were on the phone because this was one of the few times in my life where I remember having that rageful sensation of my blood “boiling” – I could feel my face turn red. I remember making some comment about “modern ethical theory evolving from the time of WWII” and hung up the phone before I got into any trouble.

This is actually one of the most disturbing interactions I have ever had in the hospital. I’ve asked several of my mentors what I could have done differently and I get the feedback that perhaps I could have explored his perspective (typical palliative care response!). I honestly don’t think I was capable. Sometimes it is frankly unfair that we in palliative care always have to be the bigger people educating these dinosaurs about modern ethics. Frankly, I wanted to just drop the gloves and go at it with fists. I still do…I’m not over it. When I see this doctor on the elevator, I cannot even look at him.

I found some comfort today though! A beautiful and important survey by Goldstein et al. showed that a large percentage of clinicians who care for dying patients have been accused of murder. The authors argue that “further efforts are needed to explain to the health care community and the public that treatments often used to relieve patient suffering at the end of life are ethical and legal.” This is indeed one implication of this study but the other important implication is that people like me who are victims of this kind of verbal onslaught have clear evidence that they are not alone.

by: Dan Maltock, MD, MPH

16 comments:

Stanley A Terman, PhD, MD said...

Dan,

You should be applauded for responding appropriately to the patient's Known Wishes.

Your handling the accuser was appropriate for both you and him: For you, it's hard to use logic when you are emotional; for him, whatever motivated this accusation must run deep.

We need more surveys, which I am in the process of developing.

If anyone is interested in participating, please contact me at: DrTerman@gmail.com
Stanley A Terman, PhD, MD
Medical Director and CEO, Caring Advocates
800 647 3223
www.CaringAdvocates.org

Gail Austin Cooney MD FAAHPM said...

Thanks for standing up for this woman's wishes, and going the extra mile by confirming them with her HCS. Many in medicine today don't understand that it's OK, even good, to die naturally, as this woman is doing. Keep up the good work!

Alex Smith said...

Yup, you're not alone Dan. Shame that it went down that way; good for you for doing the right thing. Coping with anger isn't usually part of our self care teaching. Usually it's sadness. But from your experience and from Nate Goldstein's study, it clearly is a common reaction to being accused.

Pretty convincing argument could be made that continuing artificial hydration would be battery.

There are some interesting cultural differences around fluids at the end of life. In Europe, my understanding that continuing fluids until death is standard, even for patients who are comfort measures only. Anyone from Europe who can say more?

Drew Rosielle MD said...

THE QUIET RAGE OF THE PALLIATIVE CONSULTANT.

Years ago, I successfully, as a consulting physician, managed to get an attending physician 'fired' from the care of her patient (long story, and to protect the innocent, I'll just say that I created a situation in which everyone mutually agreed to transfer the patient to a general medical service from a speciality inpatient service). The patient was dying, had severe labored respirations, and everyone, including the attending physician in question, agreed that keeping her comfortable was the best thing to do.

However when I recommended opioids for her labored resps I received this tirade over the phone from the attending phsyician along the lines of 'NO. NO WAY. I will not have any death by morphine on my service. I know all you palliative folks. You just put them on morphine and then they are dead. It's wrong. [blah blah blah]...Death by morphine....[blah blah blah]...death by morphine.'

You get the picture. All of my palliative communication techniques - reframing, education, focusing on goals of therapy, 'responding to emotion with emotion,' trying to see it from the others' perspective, being 'nice' and not being a total pedantic jackass, etc went no where. I quickly realized this was not a situation in which I was having a dispassionate, rational conversation with a colleague, but someone who was deeply cognitively challenged (when it came to this topic they were basically delusional - fixed, false beliefs, disconnected from reality - she was cognitively intact otherwise). Actually, I didn't realize quickly - it went on for about 20 minutes which was 15 minutes longer than I should have needed in order to realize I wasn't going anywhere. So I got her fired, the patient received completely conventional, routine, vanilla, symptom-directed care as she died.

But Dan, to this day, I have a lot of anger about this: her deranged accusations of Death by Morphine rattle around in my brain and piss me off. And that's why I'm writing this - because I appreciate your honesty in discussing your unadorned rage. (I say that acknowledging that The Quiet Rage of The Palliative Consultant is probably not something we should, you know, blab about on blogs a lot, but maybe there's room a little to do this.)

I do want to say that, even though there can be a perception that we're a bunch of people who wag our fingers and judge our colleages a lot (a perception that we at times help perpetuate - e.g. the widespread, knowing snickering in Denver a few weeks ago when a prominent palliative physician described herself as a 'recovering oncologist' in front of 2000 people, as if being an oncologist is something to be forgiven - not something that most of our actual patients would think about their own oncologists!)**, on a day to day basis I have fantastic relationships with the docs who consult me and my team - we help them, they're grateful, we work together to meet the needs of these complicated, hurting, need-ful patients and families. It's actually, probably what keeps me energized about doing inpatient palliative care more than any single thing.

So when these things happen, and you are reminded that you are in a profession that most people misunderstand, and a not-tiny minority view with great suspicion, and you are reminded by that by an ignorant 'Dinosaur', well that's a bad day, and I know your anger, Dan. Thanks for sharing.

**I also want to know that I had at least 5 spontaneous conversations with people in the subsequent days in which this was brought up in conversation as something which was frustrating that 'we're still hearing and people are still cheering.' I wonder if it's generational in part.

rowena said...

Sir, I am a recent graduate of a Palliative Care Fellowship program here in the Philippines; at the only institution who is offering a formal training here in our country - the Philippine General Hospital; being trained by the best. However, that is not enough because today, I am struggling with starting a practice here in Dumaguete City, Negros Oriental.
My first and my only referral as of this time, was referred for counselling only, a mid-40s advanced hepatocellular cancer. I feel sorry for this patient because, even if the attending gastroenterologist is saying that the patient is for palliative care, I feel that what is being done for the patient and the family now is just the opposite. A no opioids was ordered but the patients pain, sleeping problems are just some of the symptoms that the patient is suffering. I feel really discouraged.
After reading your article, I realize that if an advance country such as yours are having problems with the delivery of palliative care, then palliative care in the Philippines will undergo so much more. There is no room for discouragement, after all. Instead, my attitude should be to continue to strive for the best care for patients at every opportunity.

Cdot said...

I understand respecting a persons wishes. But if it goes against the morals of the person expecting to carry it out, then that responsibility should be given to someone else. I would not want my feelings disregarded to uphold someone's wishes. I'm the one who has to live with the decisions I make. The person who is suffering does not have the right to effect the employees quality of life by carrying out something they do not believe in.

But if it's not a problem for someone to carry out those wishes, then that is great for you. Carry on

Seth Bullock, R.D./dneirf-seth_bullock@usa.net said...

I am a victim of and have Intractable (Thoracic Back) Pain! It started as a result of an accident that could have killed me, in 1985. I Suffered with #9, 24/7/365 Pain for 4 years after my release from E.R.! Having been in & around the Medical Fields since I was 19, I was well aware of the HORROR that was going to be in my future, FOREVER, IF my Pain was not SIGNIFICANTLY alleviated by A.M.A.-accepted {a.k.a. Barbaric & Scientifically unsound} methods before my Pain 'graduated' from being Acute to Chronic! That meant {and still means} I had about 6 Months to discover the solution(s) that would work for me!
Long-Story-Short, after spending every Penny I had & borrowed & that my Parents had & borrowed (which included selling their Home and their investment-Duplex) and Maxing-out a combined 7 high-limit Credit Cards to pay for DOZENS of EVERY Conventional therapy/drug/treatment/Doctor that existed in 1985-1989, nothing helped & my Pain had 'graduated' from Acute to Intractable "#10" 24/7/365 Pain!
After borrowing another $25,000.00, I spent it on the most effective Alternative Medicine Therapies & Treatments that the $25K bought me! That $25K enabled me to try/use 5 or 6 of the Alternative Medicine Therapies that had the reputation & history of being the most effective on Back Pain. As we know, using Alternative Medicine Therapies & Treatments cost a LOT more than A.M.A.-approved Therapies & Treatments for reasons I don't need to expound on here. Two of them DID relieve a lot of my Pain--as long as they were being administered. But they had no effect after I left the Doctor's office.
So-- I decided to try Schedule #2 Pain Medications, and they relieved my Pain--for many successive Hours -- as NOTHING else had!!
Since May 1989, I have been PAIN FREE {even though the visible & Documented Physical damage & Trauma have actually gotten worse} because I have been Legally taking High Doses of Opioids {titrated to the level Specifically to relieve MY pain}! I have been taking 1000 mg. of Time-Released Morphine {"Kadian"} and 200 mg. to 800 mg. regular-release Morphine daily for my "Breakthrough" Pain! And after doing so for over 22 successive Years, my Kidneys & Liver & Brain, etc., have NOT experienced any negative amounts of Function due to the Morphine! I and my Doctors know this, because one of the conditions of being in the "High Dose Opioids/Opiates Program for Intractable Pain' I'm in {NOT for those with "Chronic Pain"} is having two Comprehensive Psysical Exams every Year.
NOW, I am 57! I still Drive, have an active Sex Life, am Self-Employed and have only experienced two of the typical Maladies that come with getting older {Arthritis Pain in my left knee & Presbyopia}.
There are approximately 150 others, with non-Cancer Intractable Pain, in the same Program that I am in!

I've had a Life during the past 22 years! Hundreds of Thousands of others with Intractable Pain, in the U.S.A., DON'T "have Lives" -- Because of the successful Intimidation and/or Imprisoning of some other Compassionate & Brave Doctors, used by State Attorney Generals & State Medical Boards that rely on the A.M.A. & F.D.A. generated MYTHS & LIES about the so-called "dangers" that will happen to Every One with 24/7/365, #7 to #10 Pain, who want to take {under Medical Supervision & Rules} Opioids or Opiates in the numbers and Doses NEEDED to alleviate THEIR Unique Life Destroying, 24/7/365 Pain!
There is another more accurate Name for those Doctors & A.M.A./F.D.A. minions who do that to those Doctors and those others with Intractable Pain that responds ONLY to High Doses of Schedule #2 Pain Medications: "Sadists"!!

Anonymous said...

Cdot, I agree that doctors shouldn't be required to provide treatments that they find immoral, so long as they assist the patient to find an alternative caregiver. However, the doctor simply does not have the right to refuse to refrain from inflicting unwanted treatments that he considers to be morally required. To draw a parallel to the other end of life, you can refuse to perform an abortion; you can't impregnate a patient against her will because you think she's morally obliged to bear children. Fair enough?

Anonymous said...

Cdot.

It's very hard to understand how the physician's feelings trump the patient's needs and wishes. It shows little respect for the patient, only concern for the physician's psyche.

After all the physician will go on to another patient in the next hour or day, but the patient may have to suffer terrible pain and no one knows how long.

Anonymous said...

I am horrified to think of dying a needlessly protracted, painful death due to overzealous medical intervention, and I am not alone. As a layperson, I want to encourage you and your palliative care colleagues: there are many, many people who support you and are grateful for your brave and lonely work. For anyone who has ever struggled to get a parent to accept much-needed care, it is an incredible gift to be able to say to your loved one, "Please go to the hospital - I promise you won't end up plugged into a machine if you don't want it." That reassurance is the only thing that makes some people feel safe enough to even seek needed care, and it wouldn't exist without the dedication and commitment of your field.

Anonymous said...

It's sad that in a time when we lack the resources (and will) to provide even preventative healthcare that this discussion is even taking place.

I guess that kudos are in order for Dr. Maltock although that fact indicates a much bigger problem.

Should a doctor be praised for following the clear and unambiguous directions of a patient in this matter? I guess. Seems like an obligation more than an opportunity for an "attaboy."

It's bad enough that the healthcare system doesn't help much with making end-of-life decisions or carrying them out, but to ignore patient directives is one thing only: Malpractice.

If you're a doctor that has a personal issue with certain kinds of procedures, or the withholding of treatment that's fine. State the conflict and remove yourself from the case.

Doctors want to "cure" people to the extent that it is possible. That is great, but sometimes not what the patient wants for himself.

The mountain of consent paperwork we have to sign every time we see a doctor or have a procedure implies that the patient MUST CONSENT to be treated. Granted, it is really a limitation of liability for the provider (which is fair) BUT, if the patient withholds/withdraws the consent and the doctor ignores that then s/he should be treated as if s/he performed any procedure without proper consent.

If Dr. Maltock knows that a colleague knowingly and willfully performed a procedure on a patient without consent, is it not incumbent on him to report that colleague to an ethical committee?

When someone says "you would have been hung [sic] in WWII for what you are doing now" that doesn't indicate a lack of understanding. It indicates a lack of compliance and complaining about having to "educate" dinosaurs is fine, but that doc is going to do the same thing again unless he is reported for breaking this rule just like any other.

jcrn said...

Its one of those times when you're later able formulate the perfect comeback that, in your fantasies, you use but which would actually just escalate the situation: "I suppose that would be a risk for me, but an absolute certainty for you, Dr. Mengele. ."

Herbert Mecher, MD,PhD,JD said...

Unfortunately, many physicians prefer to practice very conservative medicine when patient needs dictate a more open minded approach. I also believe many practitioners are in a legally defensive posture wanting to avoid any appearance of impropriety. The patients needs are not always paramount in the above scenarios.

Herbert Mecher, MD,PhD,JD
Miami, FL

Phil the Elder said...

Those doctors who get in the way of a patient's wish for their so-called moral reasons are actually going to increase the rate of suicide or extreme measures by terminal patients.

Such patients, probably me included, who will simply not trust the system and , give all things equal, will opt out for a quick, painless death rather than get caught in the legal and so-called moral web of some self serving doctor or system.

The tragedy might be that if a person can listen to a reasonable doctor who had a holistic view of health, life, and death options; that patient might opt to consider some treatments.

and t would be a shame for those doctors to keep silence because of some over zealous doctor who has not gotten of his pedestal and on his (or her) knees too .

Many patients are very aware of the moral and ethical issues and spend a whole life time getting prepared for the great Journey onward.

It would be a shame for some system/physician to abort that self aware journey by some well-meaning but very self centered or self seeking morality.

Thank you for this discussion. I joined it after the story on Colorado Public Radio.
Phil in Montrose

Dave Tribble said...

It is sad when a physician's mind is too made up to be confused by the facts. I will add my voice to the chorus of those who attempted to present data to colleagues who have no interest in the data.

Somebody has to be the grown-up in the room. Apparently, that falls to us.

jerry said...

Death is something that happens to all of us. It frightens us because it leads us to the unknown, even doctors. As patients, we should all have the ability to direct how the final care goes, something that reflects our values and our life.

Doctors should be there to assist and provide comfort, to the patient and to each other and not pronounce judgement like they're some kind of demi-god.