When admitting new patients to the hospital, it is important to ask them about advance directives, and I have seen students and residents alike now checking off this item. This change in practice has helped physicians to know what their patients want if a time comes when the patient lacks the capacity to communicate those choices. However, recently I was reminded of what we all learned in medical school: There is no substitute for talking with the patient.
I was on call when a frail woman in her late 80s presented to the emergency room with a partial small bowel obstruction. She had multiple comorbidities, had had multiple prior abdominal procedures, and clearly was not an excellent surgical candidate. Fortunately, she had minimal tenderness and nothing to suggest compromised bowel.
At the time of admission, she clearly stated that she did not want surgery – "no matter what," she said to my resident and to me. Her son and daughter agreed that this had been her position for several years, that she had "lived long enough" and that "surgery was not an option." They referred to her living will that stated her desire for "no heroic measures."
At that point in the emergency room, all of the doctors seeing her were optimistic that with nasogastric decompression, she might improve. None of us thought it important to convince the patient to have surgery, since we were not recommending surgery. We discussed whether she should even be admitted to the surgical service, but since she clearly needed significant fluid resuscitation, we thought that she would be best served on the surgical service.
The history and physical examination documented in the electronic medical record clearly noted the patient’s statement about not wanting surgery as well as her advance directive. This information was duly copied and pasted into subsequent progress notes and also highlighted on the sign-outs that the different surgical residents passed on to one another as they cross-covered this patient.
Initially, the patient improved and was able to have the NG removed and liquids started. However, she never fully opened up. Eventually, she became distended, and 18 hours later, her exam worsened dramatically. The night float surgical resident placed a new NG tube and noted that the output had become feculent.
At this very important point, rather than go along simply with what the patient and her family had said in the past about "no surgery," this surgical resident made a simple, yet critical, decision. She decided to have a long talk with the patient. She discussed the problem and the unlikely possibility that it would get better without surgery. She also explored with the patient in detail why the patient had refused surgery in the past. Despite her prior statements, the patient was very clear that she did not want to die in the state that she was in. The resident explained that an emergency exploratory laparotomy was necessary and reviewed the risks with the patient and the family. In light of the alternative that the patient had now experienced, she readily consented to surgery with her family’s agreement.
Her operation went well, and although her recovery, as expected, had some bumps in the road, the patient and her family are happy that she went through with the operation and recovered.
Why is this case such an important one to reflect upon? First of all, had the patient’s prior statements and even her written advance directive simply been followed, she would never have had the operation that she clearly needed and ultimately wanted to have. Second, if my resident had not taken the time to talk with the patient about her condition and her concerns about surgery, we might not have realized that as her condition changed, so too did her wishes. Finally, if the attempt had not been made to talk with the patient while she was still able to do so, her family might never have known that she had changed her mind.
It is critical to note that I do not present this case as an example of how we can talk patients into what we think they should do. Rather, this case illustrates how important it is to revisit prior decisions in light of changing clinical conditions. As valuable as advance directives can be, there should be no substitute for talking with a patient who is able to participate in the decision making. Sometimes patients change their minds, and we should remember to give them the opportunity to do so when their future health depends on the decisions made.