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Treating Your Friends

You know that ad that says, “Friends don’t let friends drive drunk?” There should be one for doctors: “Friends don’t let physicians treat friends.” Well, that didn’t really make sense, but you get the idea.

Quite awhile ago, we had this patient. One of his several doctors was a personal friend of the family. The patient eventually died, but not after having every single treatment in the book thrown at him. I truly believe that because the doctor was a close friend, he completely lost all objectivity, and was unable to see the situation as the rest of us saw it: hopeless.

He even, at one point, asked if I thought that the patient (who was trached) could just live like Christopher Reeve. On a vent. In a wheelchair. He asked me this about a man who was 50lbs. up on his weight from swelling; his lungs, kidneys, and liver had failed. He was comatose. Hell, he was a living corpse. Because the doctor refused to accept this, he kept trying herbs and natural remedies… giving the family false hope. After all, this was a man they trusted. If he said that the patient could get better, of course they’d want to latch onto that.

I finally convinced him that no, the patient could not live like Mr. Reeve, because of obvious reasons (Mr. Reeve was not in multi-system organ failure at that time, for one). I even went so far as to ask him to make the patient a no code… I didn’t even bring up withdrawing treatment at that point. I think he finally saw my point and did just that. The patient ended up dying on a ventilator and on continuous dialysis. (No code does not mean no treatment – and the family refused to withdraw.)

A few weeks ago, a 90+ year old man came into the unit with a gastrointestinal bleed. This diagnosis can go several different ways, but it usually buys you a few units of blood, some nice anti-ulcer medications, and an endoscopy. When the GI doc went to talk to the patient about the endoscopy to get informed consent, the patient refused.

Huh. Imagine that. A completely competant man who has decided that this is it. It took some doing for the man to convince his family that this was the right decision, but he managed to do just that. Since we weren’t going to be doing any intense treatments for this man, a transfer order to the medical floor was written.

Before the patient left, however, another doctor came to see him. This doctor had been treating this patient for decades and was a personal friend. The patient started vomiting large amounts of old blood, and the doctor asked me how many units we planned on transfusing. I replied that the patient refused to have transfusions. The doc’s jaw dropped and he actually said, “He’ll consent to the blood after I’ve talked to him.”

Now it was my jaw’s turn to drop. I stood transfixed as the doctor explained that bleeding to death was a horrible way to die, and surely the patient wouldn’t want to die of heart failure, unable to breathe? The patient looked a bit stricken, but then asked if it would be painful. To which the doctor replied that of course it would be painful! “Now if we could just get a few units of blood into you, you’ll be feeling so much better.”

Uhhhh… okay. I stopped the doctor outside the room and asked him what a few units of blood was going to accomplish… the patient refused an endoscope, so we wouldn’t be finding the source of the ulcer to cauterize it. He’s refusing anti-ulcer medications, so there wouldn’t even be an environment for the source of bleeding to heal. The doctor said that if it were an ulcer, of course there was a chance it would heal… and “Oh, by the way Mr. Patient… it wouldn’t be so bad to just take some medications to help the source of bleeding, right? Oh, and while we’re at it, why don’t we just stick an NG tube in so that you won’t have to throw that blood up and possibly get it into your lungs.. it’s a terrible thing to choke on that sort of thing, now isn’t it?”

To say I was appalled would be an understatement. Here was a man who had adamantly refused all forms of treatment, saying that his time had come, and he wished to join his wife in heaven. Then this doctor comes along and completely disregards this man’s wishes. I never heard the patient agree to any of these treatments. When the doctor wasn’t getting an enthusiastic response, he told the patient that his daughter really wanted him to have these treatments, as it “would make him more comfortable.” The patient stated that he no longer wished to be a burden on his family and was ready to go. At which point I thought Uh oh… now we’re going to establish depression and an inability for the patient to make decisions in his own best interest.

I reminded the doctor that the patient did not wish for any of these treatments, and the doctor again told me that bleeding to death was “a horrible, just a terrible way to die, you know?”

So I then asked him point-blank, “Then just how will you let this patient die?”

The doc didn’t have much to say to that. At this point I felt that the charge nurse needed to be brought in, so I updated her on the situation and she pulled the doctor aside to speak with him. She told him that the nurses felt uncomfortable going against the patient’s wishes, and that the patient himself told her that he was sad that a grown man was not allowed to decide such things for himself. The doctor said that he was a friend of the patient and just new that these invasive treatments were what the patient needed. The charge nurse then told him that the very fact that he was a friend made treating the patient unethical.

Surprisingly enough, the doctor agreed with her. He eventually told her that they could disregard any or all of those orders that he gave. Unfortunately, the patient’s nurse had already put the NG down, with the patient’s daughter holding his hands down while he struggled with it.

I know that excessive bleeding can cause heart failure which leads to heart attack. This is painful. Fortunately, there are many pain medications that are available to deal with this. I think we could have reasonably assured that this patient would have died peacefully and pain-free. Now that the doctor had the family all in a tizzy about these treatments (they wanted them; after all, their doctor friend said that these things would make him comfortable!), the patient most likely died with a tube in his nose, medications going through his veins, and blood products that could have gone to someone who really wanted them.

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This is really sad. I’m impressed with your charge nurse,though. She was a good advocate for both the nurses and the patients.

At first while I was reading this, I thought maybe the Dr. was sticking closely to his Hippocratic oath or was worried about malpractice, but I think you hit the nail on the head. Physicians should not treat their friends. Of course, how does one refuse without looking or feeling as if they are uncaring? Perhaps some larger code of ethics would give them the freedom and relief from that practice.

this is a great story, and one worth spreading around. as a physician in a very small town i can’t help but become close to people. i have 4 generations of some families, and after years i can’t help but get involved with them. eventually some people become more like friends than patients. when their time comes, it’s too hard to be objective- but there’s no one else. i do the best i can. i try to think how i would want to be treated myself. but sometimes, i need an outside voice of reason like yours.

Having recently moved to a critical care environment with adult patients, I fully understand what you were faced with.

It seems very simple to suggest that these doctors/friends remove themselves from providing care for these patients. But, it’s the right thing to do.

Remind me some time to tell you the tale of the respected and well-like doc who was damn near killed by the community of physicians who surrounded him, all afraid to “hurt” him as he slowly spiraled down the tube.

While your enemies may hurt you, your friends can kill you. Friends don’t let friends practice medicine on each other.

Holy God, this is terrifying. I applaud the nurses on this one for standing their ground. It can’t have been easy.

This is odd. If the patient had “adamantly refused all forms of treatment”, he shouldn’t have been in the hospital. Once it’s clear that he doesn’t want any medical intervention, he should have been discharged home to die the way he wished. If he refused not only medical intervention to find and actively treat his disease, but even basic stop gap measures like transfusion, he basically simply wanted to die.

So why was he in the hospital? I think the doctor and the nurses should have made arrangements to discharge him asap, instead of quarelling with each other. I can completely understand the discomfiture of the Doc. Who on earth would want a patient of his sitting there on the floor bleeding out in front of his eyes?

Anne: It was pretty late in the evening; besides, he was pretty much in the hospital so that we could provide comfort care in the form of Morphine or other medications that would make him comfortable.

I am a dialysis patient, and have had a few ‘disagreements’ with my charge nurse as to what a DNR code is. She insisted that if you show up at dialysis and lose conciousness, there is ‘presumed consent’ for them to do anything necessary to bring you back. There’s an unwritten rule that ‘nobody dies in my dialysis unit’– I think that makes a DNR worthless. It’s almost like they’re saying that if you elect to have dialysis, you agree to whatever they feel like doing to you to achieve a ‘good outcome’.

very interesting, but I don’t agree with you

So, what brought you to the hospital today?

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  • profileI am Gina. I have been a nurse for 15 years, first in med/surg, then CVICU, inpatient dialysis, CCU and now hospice. This blog is about my experiences as a nurse, and the experiences of others in the healthcare system - patients, nurses, doctors, paramedics. We all have stories!

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