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Posted by Dr. Lachlan Forrow February 10, 2014 12:27 AM
My father learned in law school that asking the right question is often more important than giving the right answer.
He also learned that whenever answering a question will not help your client, a good lawyer will try to change the question.
The same thing is true for doctors and patients.
Dad's 87th birthday would have been last Thursday. In honor of his birthday, this blog entry will focus on questions -- questions that have come up recently in the care of patients I was consulted on, and different questions that turned out to be more useful. In each of the cases below, it seemed clear that even a "100% correct" answer to the initial question was not going to be very satisfying to anyone -- because it was not going to help us succeed in caring effectively for our patient (or her/his family).
Figuring out the right question, rather than just answering the one that has been posed, can be difficult, and almost always takes additional time up front. But that time is also usually very well invested, and often saves time later on. As Einstein said:
"If I had an hour to solve a problem I'd spend 55 minutes thinking about the problem and 5 minutes thinking about solutions."
For each of the cases below, the "correct answer" to the initial question was not going to leave any involved doctor or nurse satisfied with (much less proud of) their care. When the alternate (and much more difficult) question was posed, in each case the doctors and nurses found a path that they all agreed led to care for their patient/family that they could be proud of.
(Note: personal details about each patient and family have been altered, out of respect for their privacy.)
1. An elderly woman with pneumonia
An 87 year old woman with advanced dementia, unable even to recognize her husband and children, is nonetheless cared for by them, with tireless devotion and heroic effort, for years at home. She is hospitalized with pneumonia, requiring intubation and life support in the ICU. Ten days later she is successfully extubated and is moved to a general medical floor, where she is not only unable to communicate meaningfully with staff, but sometimes very agitated and disoriented, pulling out IV's. Her son, her legal health care proxy, insists that she be tied down if necessary to continue her life-saving antibiotics. He also says that long ago he promised his mother that he would never agree to a "DNR" order for her. Her attending physician believes that if the patient has a cardiac arrest, CPR with near-certainty would be unsuccessful, and even if it succeeds then the patient would at most have a prolonged return to the ICU before dying there. She therefore believes that doing CPR would be inhumane. The patient's nurses (who, if the patient has a cardiac arrest, would most likely be the ones to initiate CPR, quite possibly hearing/feeling the cracking of the patient's ribs as they did it) agree completely.
Initial Question: If the patient has a cardiac arrest, do we have to do CPR?
Correct (but not satisfying) Answer: No. (BIDMC policy supports the judgment of an attending physician who determines that a proposed intervention would be "ineffective" or "harmful". The patient or family member has a right to a second opinion, and/or transfer to another facility.)
Alternate Question: How can we help this son have confidence that his mother will be cared for the way she would have wanted, receiving "heroic efforts" of "intensive caring", including everything that might help, and omitting only things that would be inhumane to even try?
Answer: It took not only substantial time listening to and reassuring the son about all the things that were being done (and would be if needed); it also took repeated reinforcement by nurses in the room, proving in unmistakably-concrete ways that they were doing "everything possible" to help his mother.
2. A middle-aged man with a massive stroke
A 54 year old man is on a ventilator after a massive, totally-unexpected stroke. Tests prove beyond any doubt that his entire brain is now "dead", though his heart continues to beat, and the ventilator continues to "breathe" for him. But he is legally dead, and normally, after this is explained to the patient's family, after a brief period allowing family to say "goodbye", the ventilator is turned off. When the ICU doctor explains this to family gathered in the room, his daughter insists that a miracle could still happen, and refuses to agree to stopping the ventilator. Other family members seem able to accept the doctor's judgment.
Initial Question: "Can the ventilator be turned off?"
Correct (but not satisfying) Answer: Yes. (Massachusetts law is crystal-clear on this.)
Alternate Question: How can we make sure both that (a) the daughter knows her views are not only heard and understood, but also deeply respected; and (b) the ventilator is stopped within a reasonable period of time?
Answer: After introducing myself to the family gathered in the patient's ICU room, I met, at the daughter's request, alone with her. Over the next 30-40 minutes, spent mostly listening and sympathizing with her, I understood why she was having such a difficult time. In addition to the nightmare of what had happened to her father, I also listened to her tell me about her aunt, hose doctors years ago had confidently said was “brain dead”. Her uncle refused to agree to stopping life support, and three weeks later her aunt woke up, and lived another seven years. After I explained why in her father's case it was biologically impossible that the tests were wrong (one showed zero blood was even reaching his brain), we returned to her father's room, and the ICU staff offered her and the rest of the family "whatever time you need" to say whatever they wanted to say to their loved one, before the ventilator was turned off. Three hours after I had first been paged, the family (including the patient's daughter) left calmly, thanking us for our care.
3. A young woman with life-threatening substance abuse
A 32 year old woman is hospitalized with fevers and shaking chills from a dangerous blood infection ("sepsis"). Several years ago she had developed a life-threatening infection of one of her heart valves from using a dirty needle to inject heroin. Her life was saved by one of our cardiothoracic surgeons, who replaced the infected valve with a new artificial valve. Last year she was re-admitted, again with a life-threatening infection from another dirty needle. Almost no heart surgeon in the U.S. would do a second "valve replacement" for a patient with recurrent active drug use, because the odds of re-infection, recurrent valve failure, and death are so high. But after the patient's mother comes to him sobbing, pleading with him to give her daughter another chance since she will certainly die without the surgery, he agrees to do the operation, which is successful.
Soon afterward, she resumes her drug habit. When she is re-admitted to us she has three different life-threatening bacteria growing in her blood culture, and the same blood sample also tests positive for heroin. When she demands higher doses of narcotics for pain from a tooth abscess she is found to have, the resident refuses, and the patient angrily announces that she is going to leave. The resident consults our legal department, who says that without a court order (a "Section 35", which we do not have) we have no legal basis for forcing the patient to stay. Both the resident and infectious disease specialists believe that if she leaves before completing additional IV antibiotics, she will almost certainly die.
Initial Question: If she insists on leaving, do we have to let her go?
Correct (but not satisfying) Answer: Yes.
Alternate Question: What will it take to get her to choose to stay, without violating any physician's (or nurse's) professional standards and integrity (including about appropriate administration of narcotics)?
Answer: On further discussion, she insists that the fundamental issue for her is respect, and that if she doesn't feel respected she will leave. After identifying and agreeing to several concrete things that she says will prove to her that we respect her (not including any compromise about the increased narcotics she had been demanding), she stays voluntarily. Four days later, a court order for treatment is obtained, and after completing her course of IV antibiotics she is transferred to a locked inpatient substance abuse treatment program.
One thing that every one of these cases took was substantial time, and most of that time fell outside of the usual categories of medical diagnosis and treatment for which physicians are paid. And each of these cases raises serious broader issues about how our health system functions (and doesn't) today. I'll be writing more about both of those issues in future "Mortal Matters" entries.
The author is solely responsible for the content.
About the authorLachlan Forrow, MD is Director of Ethics Programs and Director of Palliative Care Programs at Boston's Beth Israel Deaconess Medical Center and Associate Professor of Medicine at Harvard Medical School. More »
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