Saturday, February 11, 2012


     This story is not my personal patient. But it is very interesting and show es how sometimes human mind works.
    This was a 68 years old man who had extensive  cardiac history, had open heart surgery done for bypass.. had decrease cardiac function in spite of surgery . So he was short of breath all the time , but was doing OK with day to day activity. His congestive heart failure would flair up at times and then he would need fine tuning in his medicines and at times would need to be admitted . Since his heart was quite weak and his ejection fraction  i. e. pumping ability of heart had dropped to about 10 or 15 %. His cardiologist had mentioned to him about his deteriorating heart function and had asked him to think about  'code' status, DNR-Do not resuscitate . Normally we ask patient to do ' Living will' -which states patient's desire about aggressive and artificial medical means including feeding, . We also ask them to assign someone , in case they can not make own decision about the care ,. Most of the time it is spouse who takes over when patient can not . Sometimes if spouse is also too old or has dementia the one of the children will be assigned.
   One of these days he was admitted to hospital , with gastro intestinal bleeding . He was on many medicines which could contribute to the bleeding, aspirin , plavix and coumadine due cardiac arrhythmia . He was quite sick, and was in ICU. He needed several different consultants to see him  and needed many procedures . He needed ' central line ' to have access to give blood and fluids , needed endoscopy  to find source of bleeding . Overall he was not doing well. The cardiologist was talking to the wife and the children on daily basis to tell them the poor condition and the chance that he may not survive. The cardiologist was getting calls from hospital nurses any time there was new test was ordered or needed especially when it was invasive and they always got his OK to proceed .
    One day his blood pressure dropped . and in spite of medicines to bring it up it was not doing very well. When the hospital nurse called the cardiologist to update of his poor condition he made a comment that this patient should be DNR and family needs to make that decision soon . The nurse told the cardiologist that he was the one who is suppose to make that decision . The cardiologist did not understands , He stated that he has all ready told the family that the prognosis was very poor .and they need to make the decision . Then the nurse told him that He is the one who has to make that decision as He was the one  " who was assigned by the patient to make the decision ". He could not understand how he was  the one . When he came to the hospital , the nurse showed him the papers that stated that final decision will be made by this cardiologist AND NOT BY HIS FAMILY . This doctor was not only surprised but had big problem as the family though not ALLOWED to make decision were still involved in the care
     It appeared that the patient did not trust the spouse to make independent decision without being influenced and pressured by the children and so he assigned the cardiologist to make the medical decision .
     After talking to the family he did make him DNR and the patient passed away .

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