Anyhoo. Last week I got called out for an organ donor referral to a teeny tiny little community hospital with a not-so-great reputation. Although, in all fairness, once when I was younger I smashed my finger at work and they did a top notch job of taking my finger nail off and stitching a little laceration I had. The finger nail never grew back in the right way, but I guess that's not their fault. Anything larger than fingers, though, I'd be afraid. That's all I'm saying.
The patient was a middle aged man who had minor surgery the day previous, went home with a headache and had an enormous bleed. He came in after midnight. It's now the following afternoon. His blood pressure has been 60/30 for 10 hours. He's not on any meds to keep his pressure up, just IV fluids. He also has a lot of medical problems, but his liver numbers are good, so we proceed. The hospital called 45 minutes the first clinical was done. He's not going to make it long with his blood pressure in the toilet, so I will have to ask the family pretty quick.
I get there and the patient is in nuclear, getting a cerebral blood flow (with a pressure of 60, you're taking him off the floor? Nothing like a code in radiology, I always say). I have already introduced myself to the family practice resident who's handling the ICU. There are no intensivists, no hospitalists. Any orders needed, the attending(s) have to be called. Another WTF, as Kim would say, but whatever. When the patient returns, she says she's going to speak with the radiologist and talk with the family. I ask her if I can be present. She says no, it's a conflict of interest. I ask her if, after she's done talking with the family, could she introduce me. No, that's also a conflict of interest. Really, cause at the other hospitals I go to it's called a "collaborative approach". Apparently she can't even be SEEN in the same room with me or it may imply that "I only want his organs" to the family.
All right, let's review:
- They do nothing for the patient for 10 hours except scan his brain and give him IVF's.
- They call us late. We should get the referral when the patient has a Glasgow Coma Scale score of 5 or less, not 45 minutes after the first doc says he brain dead.
- Working together to ask a family to consent for donation is not unethical. Being pro-donation is not unethical. Possibly being a medical person and hindering the donation process may be unethical, but more on that later.
Finally, I ask the nurse to introduce us and to come in with me when I speak with the family, since she's been working with this patient all day and knows the family as well as anyone. I bring them into a conference room. There's the wife and two daughters. First, I assess their understanding of brain death and they get it. They know he's gone, they just don't want him to suffer. Understandable. Then I say to them, "Because of the way he died, (the patient) has an opportunity to save someone else's life through organ donation." The first daughter immediately says yes. Mom is unsure, but she defers to the daughter. The first daughter and the nurse both say how it would be a great thing for him to save another life and then the daughter says that he won't need his organs in heaven. The second daughter is distraught. We comfort her as best we can and she says it's okay with her. They all want to go back to the bedside and I tell them that in a little bit I'll have paperwork to go over with them, when they're ready. I give them an idea of the timeline and assure them that he will be able to have an open casket.
I go back to the nurse's station and start making phone calls. By now, a colleague of mine has arrived to help me out. We both note that the first clinical is not completed correctly. It has no time on it and it doesn't note if the patient is spontaneously breathing or not. She calls the neurologist back to see if he'll come and correct it or if we can fax it to him. I should note that the hospital system that this hospital belongs to uses a check list for brain death, for comformity and clarity, since many docs don't do this often and aren't familiar with the process. This one hospital doesn't use it, they have kept their own brain death policy. So it's just written in the progress notes. She gets a hold of him and he refuses to come back or have it faxed to him. He'll be in the next day, he says. She tells him the organs won' t be viable by then. He says that's not his problem.
The next thing I know, Dr. It's-not-ethical comes out of the patient's room and says, "They changed their mind." I'm suspicious. I go over to the daughter. She says that she wants to, but the rest of the family, the extended family who are now filling the room, don't want to. "And I can't go against the whole family." I talk to her for a bit, without being obnoxious about it, to see if there's anything I can do to change her mind. She's says she'll call if anything changes, but with a systolic blood pressure of 50 he won't last much longer. My colleague and I start packing up. I hear the resident and her attending going over the brain death policy. I offer to clear up anything for them. They just look at me. Then I mention that if this had stayed a consented case, we really would have needed a time on that first clinical for it to be accepted by the transplant surgeons. For it to be LEGAL. They go back to talking and ignore me. We leave.
Several days later my colleague gets an email from the nurse manager of the unit. I'm too flabbergasted to editorialize, so I'll just post it in full.
I also need to let you know that there were multiple complaints about the last referral in ICU by both the resident and the primary nurse with regards to the person who approached the family. They felt that she was placing the burden of approaching the family on them because she was not comfortable doing so. The resident tells me that she was placed in an uncomfortable position by your rep. In addition, when she finally did approach the family - the both stated that she was not assertive and they were not at alll surprised that the family refused. This is feedback that I am getting from my staff and physicians that I thought you should know (signed, the nurse manager)
Do I even need to say that this is complete bullshit? And hello-I did get consent. And then got it rescinded due to extended family pressure. Listen, it's hard enough to get a transplant. Why make it harder? And for the resident who's so concerned about ethics, think about this: you took an oath to preserve life. When your patient has an unsurvivable injury and you have stopped treating them in any meaningful way, the onus is now to preserve the lives of the prospective recipients. You are no longer saving one life, you're saving up to 8 lives and if you fuck it up you're potentially harming 8 lives. So put that in your Hippocratic Oath and smoke it.