ethics in the wards

[ckent]

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I just finished my neurology rotation and I came across an ethical issue that I was wondering about. We got consulted on a patient who had classic normal pressure hydrocephalus. He had ataxia, incontinence, and dementia, and head ct revealed very enlarged ventricles (the radiologist just read it as "prominent ventricles" though). The medicine team that we got consulted from has a history of consulting us and not reading/ignoring our notes though, I have no idea why they consult us in the first place. In this case, even though the radiologist read the ventricles as prominent, and my neurology attending and resident said that the ventricles were definitely enlarged, they wrote in their note "normal pressure hydrocephalus possible but unlikely given normal head ct scan". Therefore, they completely ignored our recommendation to get a radioisotope scan and consult neurosurgery. My resident just wanted to let it go and just stop following the patient since they were ignoring our recc, but it still really bothers me, because nph can be a treatable form of dementia, with serial LP's and shunts, it's possible to improve symptoms. The pt's wife is poorly educated, she just assumed that this was the things that things were, and just wanted to get her husband a wheelchair. Medicine was planning on discharging the patient after getting him a wheelchair after ruling out infection (they also think that his dementia is more of a delerium after speaking with his son, even though we spoke with the pt's wife and brother who both say that it's been a slowly declining dementia presenting over 5 months). Do you guys think that it's ethical to tell the pt's wife behind the medicine's team back that the medicine team is not providing her husband with optimal treatment? I just let it drop since that's what the resident wanted me to do, and it's not really my patient, just a patient that we were consulted on, but now I don't know if I did the right thing. My attending didn't seem to care either. I'm not planning on doing anything about it because of this, but the whole situation still bothered me, I don't know if I did the right thing. If it were my father, I'd want him to be treated.

 

[Square Pants]

I hear you man. But this sort of crap happens all the time when you get consults. If your resident and your attending are aware of the situation, I'd just let it drop.
You might try getting Radiology to look over the CT again, emphasizing that there was some confusion between the teams regarding the ventricle size, and also reiterate the pt's hx and PE. In the end, little is likely to happen that will benefit the pt. Sucks, doesn't it???

 

[starayamoskva]

It is extremely hard in situations such as this to remember that part of your job is to be the patients advocate. This is truly a difficult situation, do what's right for the patient and maybe piss off your attending or go along with the crowd.

Something as simple as an attending to attending call could have cleared this up and gotten the recommended test done for this patient.
Don't be afraid to stand up for what's right... if you don't it is unlikely anyone else will.

On the other side of the coin, maybe there was something going on in this situation that you didn't understand, perhaps a risk factor for surgery or something that the attendings were aware of that you weren't. There are a myriad of things that could be going on... since we don't have both sides of the story it would be hard to make a judgement.

 

[orion1978]

Though I don't start school until Monday 🙂, I have been placed in a similar situation at work. Basically another tech did not gather readings properly without the knowledge of the attending (also, the attending didn't take the time to closely examine the results--he normally doesn't have to if the tech does h/h job). The attending read the test as a false positive. As a result, the patient will be placed on therapy for the next 1 to 5 years. I asked several friends of mine who are in other professional fields. They advised me to present the results to the attending and ask why he read them that way. "I don't understand--could you please teach me?" If the logic is false, question it--you're only trying to "learn." 🙂 Plus it can cover your butt if you are wrong.

 

[AJM]

A very simple way to clear up any disagreements is to simply call the primary team, and talk with them about the patient, what you think is going on, and your recs. You would be amazed at how much that can resolve any miscommunication. It doesn't need to be attending-to-attending -- it can be anyone on the team giving a call to the intern or resident taking care of the patient.

It's my policy to always call the primary team when I'm on a consult service with our recommendations -- for every patient, not just the ones we disagree on. Usually if the team reads the notes, there are parts they don't understand, or they don't pick out parts of the note that I think are important. Therefore, a nicely placed phone call will help clarify what our team thinks and what we feel are important.