A Patient’s Wish or New Technology—Who Wins?

I held the letter with a sense of foreboding. The legal moniker in the left upper corner was an unmistakable harbinger of troublesome contents. I opened the letter, hoping upon hope that I was wrong. The letter could merely be about a financial matter, or a request for a patient’s record in regards to an accident or family legal matter. After all, those are common documents for a physician to receive. But alas, my initial fears were confirmed. The letter was indeed a notice of intention to sue me, proclaiming that I had been negligent—that I had committed malpractice.

I sweated profusely, searching frantically for the specifics of the allegation. I found the name of the patient, my accuser at the top of the document. After what seemed like forever, I found the accusation buried in the letter’s legal lexicon. The claim was that, in the course of inserting a PICC (peripherally inserted central catheter), I had broken the patient’s arm.

The Patient

Despite the months that had passed since I last saw her, I remembered the patient, Ms X, and my interaction with her vividly. 

Ms X had the ravages of end-stage multiple sclerosis. She was pathologically frail, decrepit really. Her arms were severely contracted, locked in immobility against her sides, and covered with purpura from numerous IV starts and needle sticks. Her abdomen was tensely distended, a consequence of the bowel obstruction from which she was suffering. Her skin was friable with areas torn by tape dressings and the gloved hands of her caregivers. Though she was on a morphine drip, she was miserable. Her misery was not lost upon me. After 28 years of clinical practice, I was appalled by her condition. Despite her infirmity she was awake, aware of her surroundings, and could speak. That made it worse. That made her misery all the more real.

Unanswered Questions

As I read and re-read the letter, questions began to well up faster than I could find answers for them. I wondered whether I indeed had broken her arm? It was certainly possible. Putting in the PICC required the nurse to hold her rigid extremity away from her body far enough for me to visualize her basilic vein with the ultrasound probe. The mere act of passive movement caused her pain. The procedure seemingly had gone well; it had been done in a technically proficient, smooth, and efficient manner; clearly testament to my years of practice, to insertion of nearly 10,000 prior PICCs. I had felt good about the successful line insertion in the setting of such an anatomically challenging patient. But had I broken her arm in the process? 

I could have. 

Her skeleton had been riddled by the ravages of her illness, leaving her rigidly immobile and bed bound. Her bones were nearly translucent on X-ray. She had previously fractured both hips. Had I broken now a third extremity? 

I could have.

Or was this a baseless accusation? Was it against me personally? Was she lashing out against the medical profession, perhaps against doctors in general? Did she hold us in some way accountable for her current situation? Or had I truly injured her? 

I became angry. Why had I been placed in that situation? Why had I been asked to perform a procedure on so fragile a patient, and one so distressed? I had told myself at the time that the procedure would make her hospitalization easier, would result in fewer needle sticks, and would provide better access to hydration and to nutrition. 

But was this truly in her best interests? Had the plan been explained adequately? Had I accurately explained the nature of the procedure I was about to perform? Were the goals of her hospitalization actually delineated? 

The successes of our technologic achievements had allowed her to survive and leave the hospital. But did she truly want to live like this, a pain-wracked, contorted metamorphosis of the woman she had been? 

Resolution

At the time of this writing most of my questions remain unanswered. All this uncertainty is due largely to a legal process that prohibited me from discussing the case with the patient's other physicians, with my colleagues, and with the patient herself. 

The case has since been resolved. I was dropped from the suit and the medical center settled for a nominal amount, below the reportable limit. Still, I am left wondering. Did we genuinely serve the best interests of this patient or did we become lost in our technical capabilities? Had we forgone the humanistic considerations of Ms X’s care? 

In much the same way that I had reveled in my successful PICC placement, have her physicians deluded themselves with their ability to keep her alive, while disregarding the overall consequences of their ministrations? Despite their best intentions, have they ultimately harmed her? 

They may have. 

Did I harm her? 

I may have. 

My thoughts since I received that letter have been disturbing. Is it possible that we have created a system in which we deliver complex, sophisticated health care without a clear understanding of the patient’s ultimate wishes? One in which even patients and their surrogates accept this care without regard to quality of life? Have we developed a health care system where these questions must be resolved through a legal process that perpetuates lack of authentic communication around these issues? 

In the end, did we harm her?

We may have. 

Acknowledgements: The author thanks Nancy Greengold M.D, for her review and assistance with the preparation of this manuscript.

Mark Ault, MD, is a professor of clinical medicine at Cedars-Sinai Medical Center, Los Angeles, CA, and director of the Division of General Internal Medicine. Currently board certified in internal medicine, critical care and emergency medicine, his primary clinical focus is in procedural medicine and has developed a "Procedure Center" at Cedars-Sinai Medical Center staffed by a team of "proceduralists." His primary areas of research include techniques to enhance procedural training and patient safety.