Рatient declining operation

I would like to share with you rather an incredible experience I had during my last on-call weekend and would like to invite some comments on ethical issues regarding the case.

53yo female presents to ER with abdominal pain and dehydration. Four days prior to admission the pain started in the back, radiating towards the umbilicus, accompanied by vomiting and diarrhea (no blood). She had just come back from a trip to the Carribbean islands and thought it was due to some form of gastroenteritis so she delayed coming to the hospital until the pain got almost unbearable. History of BII gastrectomy for perforated gastric ulcer 13y ago. Lost 4 fingers in her left hand after an accident with lawn mower, difficult rehabilitation.

On admission

  • BP 70/50, P 120, clearly dehydrated.
  • Abdomen distended, no bowel sounds, guarding in all four quadrants, but pain mainly lower abdomen, no herniae.
  • WBC 6’000, CRP >300. Significantly elevated Crea/BUN (3xnormal)
  • AbdXray: mildly distended Cecum, no air in rest of bowel
  • Abdo US: distended gallbladder no clear cholecystitis, one stone in infundibulum
  • CT-Abdomen: almost same findings as on US, distended loops of small bowel filled with liquids

After 5 hours of investigation by my medical colleagues (I don’t want to tell you all the other tests that were performed, lest somebody has a fit reading this note up to now) I was consulted to see the patient.

Clear cut case of peritonitis with sepsis and renal failure, vital signs had improved slightly since admission. My guess was delayed presentation of acute appendicitis. I discussed the necessity of immediate operation with the patient and… lo and behold she declines !! She was clear in her mind, no obvious signs of disorientation or delirium. I again specifically pointed out, that she might die without an operation, discussed the risks of organ failure into detail etc. again she declines.

Although I usually don’t have problems discussing medical problems in clear terms with patients I thought at this point that maybe it was possibly me who was unable to get the point across, so I called an in-house attending colleague to discuss the whole thing over again with the lady in detail… again she declines. His also was of the opinion that the there was psychologically nothing wrong with the patient.

Getting to chat a bit with her again I sense immense scepsis towards any form of surgical intervention due to her prior experiences (history, stated above). I try to quietly discuss the whole problem over again, repeat pointing out a potential life threatening situation…she declines surgery (“..give me some antibiotic treatment and we’ll talk things over again in the morning, I’m sure things will turn out fine…”) I would like to get realtives to talk to her, she is a widow has friend who lives one hour away. I discuss things over with him, he agrees to come but doesn’t think he can change her mind.

According to our laws (discussed same evening with juristic expert) the alternatives are:

  • 1. This patient clearly doesn’t want an operation, cannot be declared incapable of managing own    affairs: so treat conservatively and wait
  • 2. If (or rather when) she goes into cardiac or respiratory failure can be treated by operation, if she doesn’t clearly state otherwise, which she surprisingly didn’t.
  • 3. Cannot coerce patient (which I certainly would never do anyway); i.e. declining to do the operation later when it might be too late

Quite a grotesque and frustrating situation for me (it went towards midnight now) so I had to wait. In the end her friend manages to convince her to have the operation (it’s 2 a.m. by then) and I tiredly find a necrotic non-perforated gallbladder at laparatomy with local biliary and generalized fibrino-purulent peritonitis. Uncomplicated cholecystectomy.

Any comments? What juristic alternatives do you have in your countries?

(I would like to clearly stress that the point of this note is not to discuss any management “delays” or “diagnostic overkill” by my medical colleagues, I think we’ve been through all that before!)

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