There are worse things in life than death

Recently, I had a very unfortunate interaction with a colleague who happened to be a general intensivist. I was looking up the patient I was meant to be operating on and the patient would likely need a mitral valve replacement in the context of endocarditis. From review of the patient's chart, I quickly identified that there were indications for surgery such as heart failure secondary to valvular dysfunction and persistently positive blood cultures but there were also elements of the case that made it a bit more complicated. This patient was awake but intubated, had experienced an embolic stroke very recently, and had no fixed address with a background of polysubstance abuse. While certainly none of those are contraindications for surgical intervention and despite being very young, they require a conversation and certainly informed consent.

I proceeded to go see the patient and when I asked the patient if they would even want surgery, the first answer I got was a head shake no. Given that this decision is certainly a life and death decision, I wanted to get a collateral history from the intensivist responsible for the care. There were no family members or other individuals that I could contact.

This is where the story gets very uncomfortable. The intensivist comes to the bedside, I express my concerns and rather than acknowledging any of them, simply states that he doesn't actually know the patient, he only just received handover. He proceeded to ask what the problem was and if the patient was refusing surgery

I replied with yes, and that my concern was whether or not the patient understood the magnitude of what was going on and whether or not the patient was a surgical candidate in the first place. The patient would likely get a tissue valve because of the unlikelihood of being able to manage warfarin, which at such a young age would most certainly require a repeat intervention, there was also the concern of risk for prosthetic valve endocarditis.

Rather than even pausing to listen to any of my concern, the intensivist storms into the patient's room and proceeds to speak at the patient (not to the patient) and says "Hi my name is Dr..., you have an infection in your heart, they need to replace your valve, if you want to die then they won't operate, but most people would say they want to live, do you want to live?"

At this point, the patient nods yes. The intensivist looks at me and goes "There you go"and immediately leaves the room without another word.

Now I have a huge problem with how this unfolded for many different reasons but let's highlight some of the key bad behaviors.

1. Disrespect for a colleague and the patient

2. Lack of informed consent

3. Paternalistic doctoring

I continue to think over and over again why this interaction had to go the way that it did and I can only wonder if I had been a faculty surgeon would he have treated the scenario any differently?

I believe this patient needs surgery but I will not be the person living with the decision. Scaring patients into a decision is never the right approach. I titled this entry "there are worse things in life than death" because I have seen it. Having a stroke, living on a ventilator, never returning to baseline function are lifelong problems and are not ones to take lightly and to make that decision requires informed consent.

Anyone who knows anything about teamwork or being a part of a team knows that often times all anyone wants is to feel like their concerns were heard, not dismissed. And I think too often in healthcare we need a little reminder that the patient is the priority and not our egos.

Drop a line if you have a similar story or any thoughts to add!