Wednesday, April 6, 2011

It's Time

I was asked to see a 95 year old lady with severe abdominal pain a few weeks ago. She had been admitted to the hospital with complaints of fatigue and chest palpitations. Suddenly one morning she developed severe, sharp abdominal pain. Her heart was racing in the 130's. The Xray technicians were just leaving her room when I arrived. Now I know what you're thinking: 95 years old, what the hell is a surgeon doing on the case? But this was a sharp old broad, entirely in control of faculties. She grabbed my ID to make sure she heard my name correctly. "I'm in a hell of a lot of pain doctor", she said.

Her code status was DNR-CCA, meaning that, in the event of cardiac or pulmonary arrest no invasive life saving maneuvers were to be done. When I pushed on her belly the diagnosis was clear enough. She had peritonitis, likely from a perforated ulcer or perhaps diverticulitis. The x-ray eventually confirmed free air. I quietly informed the lady of her predicament. She told me to hold my horses, as her daughter (POA) was on her way in.

I spoke with the daughter on the phone to prepare her. I told her that her mother had sustained a catastrophic intra-abdominal event. I further told her that time was of the utmost importance; we had to determine how aggressive we were going to be, ASAP.

We met at the bedside. The daughter looked understandably strung out and stressed. Her eyes were raw red open wounds. She had seized her mother's pale hand with two of her own, as if she was fervently praying. "I think she wants you to do the operation", was the first thing the daughter said to me. Her voice trembled. She wouldn't let go of her mother's hand. She looked like she had run up the four flights of stairs to get here.

This is where the art of medicine comes into play. I have made the mistake of operating in this situation before, when I was a less experienced surgeon. I used to think it was enough to objectively present patients/families with the options, like a mechanic at a oil change shop. Option A, operate with certain complication rates, including the possibility of death. Option B, palliative care with death to ensue sometime soon. It's your decision. I will support whatever it is you decide. And then to step back, put the onus of responsibility on their shoulders. Sometimes the choice is too overwhelming. The patient is suffering. Please just do whatever will make the pain stop, she pleads to her daughter. What if the pain medications dont work they wonder. Maybe she will be one of those rare patients who survive the surgery and get better. After all, Mom just had lunch with me yesterday at Olive Garden. And so doubt begins to creep in. Doubt about advanced directives and code status orders. It's one thing to fill out end of life documents in an abstract, detached manner years beforehand. It's quite another when actual life rears its unyielding head and strikes at you with its ferocious inexorability. And so adult children of these dying elderly patients will ask----can you save my mom?

I have saved a few. I remember one 89 year old guy I operated on for toxic megacolon. He miraculously survived the subtotal colectomy and was sent to a nursing home. I remembered him as a personal triumph, a transient victory over the brute relentlessness of death. I may have even blogged about it, I can't remember. The story didn't have a happy ending though. I got consulted to see him 8 months after that miracle surgery. He was in the ICU with sepsis from a decubitus ulcer. His granddaughter told me he never really regained his mental or full physical faculties after the surgery, despite the intense rehab. The ileostomy was a constant source of stress and irritation. He had slowly withdrawn into himself and rarely left his bed. He had become a living ghost of the man she had grown up with. He died shortly thereafter.

Sometimes you have an obligation to present a patient's options in such a way that sort of pushes them in one direction over the other. Call it paternalistic if you will. I call it humane.

I told her that an operation would be very difficult (she had had numerous previous surgeries over the years and had an obvious large ventral hernia). I told her that it's certain she would leave the operating room intubated and highly likely that she might never get off the ventilator safely. I told her that many of her organ systems were already starting to fail and that often that process was irreversible, especially in someone her age. I told her that aggressive pain control was an intervention in itself, that she ought not to consider simple pain alleviation as "doing nothing". I told her I would support their ultimate decision....but a surgery would be very tough for her to tolerate.

Well, I've never been one to drag things out, she said. Get me some pain medicine. I don't want any surgery. What are you crying for, she said softly to her daughter. When it's time, it's time.

I sometimes forget how courageous human beings can be if you give them the chance.


Anonymous said...

Yes, thanks Buckeye.

Since I cannot be sure you will be around :) I have made a pact with someone (another RN) should I become a "hot mess", as I just can't trust family to keep my wishes of not wanting to linger in half-life. She, a natural born enforcer, just like me, will stand vigil and not hesitate to shoot all specialty scavengers.


drbculp said...

Great post! I'm a second year surgery resident and am often faced with this predicament. I hate to think of people leaving this Earth having spent their last days on a ventilator and struggling through--or even their last DAY. This was heartfelt and real. Appreciate the thought!
--Brittney i.e. DrBCulp

Bianca Castafiore? said...

A very fine post.

I would trust you and would likely be steered by your recommendations.

However, as an actively ill and increasingly disabled middle-aged person, I fear more and more being subject to someone else's opinion of my quality of life.

There actually is a slippery slope. I ride up and down it all the time.

Thanks for another thoughtful piece.

rlbates said...

Tough decisions. Nice post, Buckeye

Anonymous said...

Ummm just an uninterested voice from the dark side of the Brain/A-Hole barrier
couldn't it have been just a hot appy?(I love sayin "Hot Appy":)??
and I know, old people suck, what with there Social Security, and fragile veins, and 82 different medications 1/2 of which weren't even around when I was in med school..
Oh yeah, "Free air"(I just love sayin "Free Air":) means there's a hole somewhere there shouldn't be...
I remember a case just like this, turned out to be an aspirin-sized hole in the stomach from the 81mg of Aspirin she took everyday so she wouldn't die at age 97 of a heart attack..
Surgeon stuck some of that stuff that hangs down from the stomach over the hole and he was done before I'd started my MAXIM article...


Bongi said...

nice post. i like it when the patient gives clear directives. makes the decisions easier.

Jeffrey Parks MD FACS said...

All dickishness aside, you do raise a couple of points that I can actually comment on. Number one, you don't get free air under the diaphragm from an appy. Number two, I have done plenty of 30 min Graham patch/lavage cases for perfed duodenal ulcers and usually the patient does well. But this lady had train tracks across her abdominal wall along with an incarcerated ventral hernia. Moreover, her kidneys were already in failure and she was in respiratory distress. She was tachycardic with marginal BP's. In other words, multiple organ failure had set in. The odds of her pulling through the surgery were extrememly low. Ultimately, she passed away a few hours after deciding not to intervene.

Anonymous said...

"dickishness"??? I LIKE it...
I've been usin "asshole-olic" all these years..
and I meant to say "perforated" appendix...and while I appreciate the economic stimulus of the Funeral Home/Probate/, and the small(every little bit helps!) improvement in the Social Security/Medicare Lockbox account with your patient leaving this mortal coil couldn't THIS lady have also had a simple perforated ulcer???
I know, her abdomen would have been scarier than Nanci Pelosi without Botox, I mean Jim Tressel's deleted emails, and you'd have had to manage those pesky electric lights and probably leave her guts out in the open with one of those baggy things....
Ummm come to think of it, that 97 year old lady probably died at 98 or 99 anyway...


PS whats with the Cavs??? they don't watch out there gonna lose that #1 Draft Pick...

CT tech said...

The correct term for most radiographers is "technologist" not "technician."

Assitant Professor
M.S. ARRT (R) (CT)

Anonymous said...

Nice post Buckeye! And who really cares CT tech. Move on.

Anonymous said...

All Frankishness aside...this is a really well written post, Buckeye. My mom is 98 and completely well but for her eyes (AMD). You made me envision the day when something gives--those fragile veins or organ walls. She's got all her directives in place, but I hope the last health professional caring for her is someone as rational and empathetic as you. Melly

Anonymous said...

I often find myself in similar situations. I think we've gone a bit too far from the paternalistic model and too much towards the "you choose" one, which invariably leads to expected bad outcomes.

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