Sunday, March 23, 2008

Fact and Fiction

It's been an interesting weekend. I got a patient on Saturday who came in with "10/10" crushing chest pain after shovelling snow that morning. In the ER he was started on a nitroglycerin drip and given morphine which brought the pain down somewhat. The ER's story was that he had a heart attack 12 years ago that required stenting, and was due for another catheterization (a means of looking at the coronary arteries) next week. A scary story, very suggestive of a serious problem, probably another heart attack. Fortunately, I looked at his records before seeing him.

I went down to the ER and got his story. He said he had the heart attack in a different city but did not remember the hospital. He had another catheterization at my hospital 7 years ago, but said he had not had any further work-up since. I asked specifically if he was sure, and he again confirmed his story. The problem was that the records I had seen said that he had had several catheterizations, all at different hospitals, in the last five years. The last one was 5 months ago and was completely normal. Also in his records was a history of Munchausen syndrome. However, he was so serious, I considered temporarily that the resident who dictated his last discharge summary had been mistaken. So, I called the other hospital and had the records faxed over--the previous resident had been correct. The patient was flat out lying to my face. Not only had his arteries been healthy, but there was no note of the cardiologist having seen any stents--was he lying about his previous heart attack as well? Even given this, we still had to admit him--boys who cry wolf can still really be attacked by wolves. We admitted him and checked enzymes and EKGs multiple times throughout the night. All were negative. He repeatedly asked for morphine. We refused, and he left against medical advice the next morning.

It was a fascinating case. I've read and heard about Munchausen but never really grasped it until now. I was just blown away that someone could lie like that--especially given the fact that he signed the paper giving me permission to get his records from the other hospital! Either he thought I was really stupid, or he's not the brightest faker ever to waste the hospital's and taxpayers' resources. And I'm flabbergasted--what would make someone want to be in the hospital and have unnecessary, risky testing done (he also had a history of wanting surgery he didn't need)? Does he just crave attention? Is he just drug seeking? I don't think he is a hypochondriac (hypochondriacs really believe they're sick, Munchausens don't).

On the same day, we had an interesting ethical situation. We had a patient who was brain dead, in other words, her heart was still beating since we had her on a ventilator and were pumping her full of drugs, but she had absolutely no neural function. For all intents and purposes this meant she was dead--not in a vegetative state--for her to wake up would be just as miraculous as a skeleton regrowing flesh. She had a very large extended family visiting. The resident was planning to meet with them and tell them that the patient was dead and they should say their goodbyes before she was taken off the vent. However, the attending who was covering for the week walked in, smiled, and told them that her heart and lungs were doing great and that the neurologists would do a test of her brain. The family in the room sighed with relief and thanked God, thinking that there was now a chance of the patient's recovery. The residents' jaws dropped open in shock.

Immediately after in the residents' room, behind a safely closed door, the attending and residents argued for about 20 minutes about the proper way to handle the situation. The attending was adamant that he had just provided the family with hope, and that they should slowly, over the next day or two, break it to them that that patient would not recover. The residents (and I, silently) were strongly of the opinion that they needed to be honest. The attending didn't give in, and left. The residents then spoke to the neurology consult attending, who was understandably furious. He called our attending to yell at him, then met with the whole family and told them she was dead. They took it well, and said their goodbyes before her heart stopped the next morning.

This episode has been the subject of much discussion over the last few days. I think it demonstrates a great difference in the way that different cultures and generations think about death and the role of the physician. Our attending was an elderly Asian man, and came from an era and a culture in which physicians took a paternalistic approach and gave patients hope even when there was none. An era in which they could start chemotherapy without ever informing the patient that he or she had cancer. We, and virtually all doctors in America today are products of informed consent, in which there can be no greater travesty than to be anything other than brutally honest with a patient, even when it hurts. Maybe we're wrong, or at least not totally right. But it's how I would want to be treated.


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