Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
11 July 2007

MEDICAL DILEMMAS

            The field of healthcare and medicine is rigidly controlled and ruled by policies and procedures.  The goal of these policies and procedures is to deal with every possible event that might occur.  But in spite of all our efforts to be prepared for what may come, situations do arise that just don’t seem to have a good answer.  The question boils down to, “What do you do when you don’t know what to do?”  Below are two true stories that present such a dilemma.

            The lady was 68-years-old and she owned and operated a jewelry store.  Her husband had passed away in the past year and she had been very depressed for obvious reasons.  It was December and she very much wanted her son and his family to join her at her home for the holidays.  But the son indicated that he had other plans already made to go to Florida for Christmas and invited her to come with him.  She declined saying that she just didn’t feel up to a trip like that.  She again pleaded with him to change his plans but he would not.

            On the morning of December 21st, she did not arrive at the jewelry store as she normally would and an employee called to inquire.  Receiving no answer, he went to her home where she was found comatose in bed with an empty bottle of sleeping pills at the bedside.  She was still breathing so he called an ambulance and she was brought onto the hospital.  She was diagnosed as having taken an overdose of sleeping pills and procedures were begun to support her breathing and vital functions until the sleeping pills wore off.  Her next of kin, her son, was in route with his family to Florida and could not be reached.  The next two hospital days were uneventful as her blood pressure and breathing were supported.  She was treated with intravenous fluids to maintain hydration.

            But on the third hospital day, the condition changed.  She developed a gallbladder problem that required immediate surgical address.  This was a medical emergency.  By this time, her son had been located and apprised of the situation.  In as much as the lady was still comatose, she was not able to give informed consent regarding the surgical intervention necessary for her gallbladder.  The son did have medical power of attorney and was asked if we could proceed with the necessary surgery. 

            He declined.  He said he knew that his mother was depressed and really didn’t want to live or she wouldn’t have made the suicide attempt that she did.  He demanded that further life support be discontinued saying that this would have been his mother’s wishes especially in light of her suicide attempt. 

            It is well known that many individuals in times of grief make a “suicide gesture”.  An overdose of sleeping pills is a very common practice in this situation.  Many, many times, the individual is resuscitated and recovers; the depression can be effectively treated, the grief- causing event passes, and the person’s life goes on well worth pursuing.  Thus, the physicians caring for her did not share the son’s perspective and felt that lifesaving gallbladder surgery was an appropriate step in care.  But the son had medical power of attorney and was legally entitled to make the decision on how to care for his mother.  He was also heir to the jewelry store.

            What is the moral obligation for the healthcare providers caring for this lady? What are the legal obligations in light of the son’s conflict of interest? 

            I was peripheral to this lady’s care but very disturbed by what I considered to be cumbersome and inadequate care that she received.  Her permission for surgery was denied by the son’s power of attorney.  The hospital’s lawyers apprised the surgeon that he could not proceed with potentially life-saving surgery.  The patient expired two days later, fortunately, never regaining consciousness.  It is my personal opinion that this case bordered on legal murder.  Over the next several months, it was the topic of discussion many times and to my surprise there seemed to be about as many opinions stating that the hospital acted appropriately as stating that they did not.  I have heard arguments in both directions.  In my opinion, the healthcare providers total obligation is to the patient and to act in the best interest of the patient.  I don’t for a minute believe that is what happened in this particular case.

            To change the subject and consider a second case, a gentleman came to the clinic stating that his father and his father’s brother had both died in their 50’s from stomach cancer.  The patient stated that he had three brothers that all had died of stomach cancer in their 50’s.  The patient said that he was 48-years-old and he wanted his stomach removed now.  He had no symptoms, he was not losing weight, and his stomach did not hurt.  Blood tests were done and all were normal.  An x-ray exam of the patient’s abdomen was within normal limits as was a chest film.  An endoscopy was done to exam the patient’s stomach and no abnormality was identified.  Washings were taken of the stomach lining and found to be normal.  What is the appropriate step in care to deal with this gentleman’s clinical situation?

            After I had finished this gentleman’s workup, I presented the case to the surgeon who stated that he saw the merit in the gentleman’s concern but that he could not remove this normal stomach by any medical principle that he had ever practiced with.  I referred the gentleman to a university medical center and they also stated that his story and request seemed to have merit but they would not take his stomach out either.

            The above gentleman was lost to follow-up and I have never heard from him again.  I don’t know whether he did develop cancer of the stomach himself or not.  I understand the reluctance of surgeons to take out an apparently normal stomach.  But in reality, I am not sure that this was a normal stomach.  The story behind it certainly wasn’t normal.  I question that the best choice for this patient was made by the physicians caring for him; the patient’s request was not honored.  Not many physicians I have discussed this case with would opt to remove this man’s stomach.  But when I turn the question around and ask what they would do if they were the patient, most would want surgery to remove the stomach.  There is something wrong with that.

            Dilemmas in medicine are frequent.  Rarely is there consensus on the proper choice.  It all goes back to one of the first laws of nature, “Nothing is ever easy!"