The importance of End of Life Issues

although this is an issue that many folks in this country like to ignore, in a hospital setting this topic is very important. I recently had a case where the gentleman presented from an outside hospital with a perforated colon. Luckily, he was able to get to our hospital in time and to the operating room where they were able to remove a good section of the affected colon. The patient became somewhat hemodynamically unstable during the surgery and they had to stop early and planned for a return to the OR the following day.

The difficult aspect of this case arose when both the son and the second wife appeared and claimed that they had health care power of attorney over the patient. This became quite a conundrum since one family member noted almost diametrically opposite from the other. We referred this case over to our risk management department and they sided with the family member who had appropriate paperwork. Apparently the patient was deemed incompetent and had guardianship transferred to one family member, and the other family member had papers that were signed after the patient was already declared incompetent (likely due to Alzheimer's).

Regardless, the patient became very unstable and the family member who had guardianship made the patient DNR, or do not resuscitate. Everything was being done for this patient, mechanical ventilation, fluids, medications to maintain blood pressure and heart rate (pressors), etc. However, the family member who did have power of attorney did not desire to have chest compressions done. The patient eventually expired.

The entire episode became a family circus when the other family member who did not have guardianship objected to the decisions the other family member made. The moral of the story is that you should have any plan or discussion with your family members in the event that you become critically ill. It is unfair to put the burden on Hospital staff to make decisions that you should have had with your family members. The general public also needs to understand that dying is a natural process, and prolonging life on artificial means leaves little to no quality of life. Are you planning on taking your loved one home on a mechanical ventilator? Or perhaps you could just be like most of America and leave the burden of care up to the hospital...

Medical Treatment for Prisoners?

So this week we had a patient coming to us from the state prison. The short story is that this individual was sentenced to prison for larceny. I did not ask for any more details regarding the individual's imprisonment. But the medical story regarding this individual is that a patch was placed during childhood to repair a ventricular septal defect. Apparently this patch became infected and needed to be removed, and this was successfully done during surgery. However, during the case the tricuspid valve of the heart was so terribly infected that it too had to be resected. The repair made to the tricuspid valve did not hold after surgery. At this stage the patient may require additional surgery to repair the initial valve.

But this Prelude brings me to my point. Once you commit a crime and you are sentenced to prison, you essentially become a ward of the state. If you need some kind of medical care, you are guaranteed to get it if you are incarcerated. I think it is more because you are a ward of the state rather than a criminal. Hospitals have no problems accepting patients from the prison system since it is guaranteed revenue for them. Sure, they often send regards to accompany the patients, but there are instances where prisoners have tried to escape from hospitals. Is it really necessary to put the rest of the hospital staff at risk?

From a philosophical standpoint, there is definitely a disconnect here in that you can break the law, be sentenced, and then qualify for medical care you would probably not have received otherwise. The other alternative is that you can be a law-abiding citizen, have no medical insurance, and then be denied medical care that you probably need. Which option would you rather have if you are faced with a life-threatening ailment?

Sure, in medical school we are taught to not pass judgment on patients. But the thing you have to remember is that we are human. Above that, hospital staff generally obey the law rather than break it. So why should I take comfort in treating someone who probably murdered another innocent individual? I thought that these individuals forfeited their rights once they decided to commit crimes against society. So even if they are wards of the state, why should society get stuck footing the bill for their health care when we cannot even cover most law-abiding citizens?

For example, there was a shooting in the past week in Columbus, Georgia, where a grief stricken individual shot and killed 3 individuals. The shooter felt he was targeting a nurse who had taken care of his mother when she had died there in 2004. The unfortunate instance is that the individuals shot and killed had nothing to do with the shooter's mother's care. The shooter was shot in the shoulder and had orthopedic surgery. Why should this individual have deserved surgery? He did after all kill 3 people. This is probably a surgery the med students should have performed, it is definitely not worth the time of anyone else!

So the moral of the story of is if you are uninsured, just go shoplift or embezzles some funds and you can wind up in prison. Afterwards, you can get the chemotherapy or surgery you need...