Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today's case will be the first in an occasional series. --PalMD
Mrs. M is an 89 year old woman who resides in a nursing home who was admitted with confusion and lethargy. She has a past medical history significant for stroke, coronary artery disease, depression in the distant past, and no history of dementia. She has lost significant weight over the last 12 months. She participates in social activities with her fellow nursing home residents, but prefers to spend time alone. She is a retired registered nurse and a widow.
On the day of admission, her nurse found her to be much sleepier than usual, and when she spoke, she wasn't making a great deal of sense. An ambulance was called and she was brought to the emergency department.
On evaluation, she was noted to be a frail, elderly woman who was conscious, but disoriented. Her blood pressure was slightly low, her heart rate was normal, and she had a low-grade fever. Her mucus membranes where dry, with minimal skin tenting. She was able to follow basic commands. Her heart was regular, her lungs were clear, and she had some vague, generalized abdominal tenderness.
Laboratory examination revealed a somewhat low white blood cell count, mild anemia, and white cells in her urine. She was admitted to the hospital for urinary tract infection with sepsis, and was started on intravenous fluids and antibiotics.
Throughout the night, she became more confused, and her systolic blood pressure dropped into the 80s (which is quite low). Repeat blood work showed an elevated creatinine (indicating poor kidney function), and mildly elevated cardiac enzymes. Her urine and blood cultures subsequently grew out two distinct types of gram-negative bacteria.
While the intern worked on transferring the patient to the medical intensive care unit (MICU), the senior resident went through her health records in more detail. The patient had filled out an advanced directive, which contained the following statement:
If I have a terminal condition I do not want my life to be prolonged and I do not want life-sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death.
She had also designated her niece to be her surrogate decision maker if she were to become unable to make her own medical decisions. Her niece had signed the advanced directive indicating that she had read and understood it.
The senior resident called the niece to inform her that the patient was not doing well. She also went over the contents of the advanced directive and let the niece know that her aunt's wishes would be respected. The niece became upset, and demanded that "everything" be done, and specifically demanded that no "DNR" order be given. The resident gently explained that she would have to respect the written request of the patient. The niece stated that she was the only legal decision maker, and that she was calling her lawyer. She then hung up the phone. The resident walked into the bathroom, cried briefly, then returned to the floor.
There is a clear conflict in this case which needs immediate resolution. The patient is in extremis, so this can't wait for morning rounds.
1) What can the resident do to get help making a decision?
2) What are the salient medical facts that inform her decision?
3) What ethical principles inform the actions of the doctors and the surrogate?
4) What would you do?