Downloaded from http://spcare.bmj.com/ on July 12, 2015 - Published by group.bmj.com
Case report
A morbid reason for consent Fay Murray-Brown,1 Llion Davies2
1
Department of Palliative Medicine, Derriford Hospital, Plymouth, Devon, UK 2 Department of General Surgery, University Hospital of Wales, Cardiff, UK Correspondence to Dr Fay Murray-Brown, Palliative Medicine, Derriford Hospital, Derriford Road, Plymouth, PL6 8DH, UK; [email protected] Received 27 September 2013 Revised 7 February 2014 Accepted 28 February 2014 Published Online First 20 March 2014
To cite: Murray-Brown F, Davies L. BMJ Supportive & Palliative Care 2014;4: 303–305.
ABSTRACT We report the case of a recently bereaved elderly lady admitted on the acute surgical take who gave consent for emergency surgery in the hope of dying intraoperatively. To her dismay she survived and, thereafter, refused all food and medical intervention leading to her death 15 days later. This case highlights concerns regarding both the process of consent following emergency admission and failure to identify a vulnerable patient’s wishes.
BACKGROUND Informed consent prior to surgery is an integral part of modern clinical practice, usually considered a process,1 that starts at initial outpatient consultation for elective patients. However, this ideal scenario cannot be replicated for emergency admissions, as on-call surgeons have limited time, and delaying surgery may result in poorer patient outcomes. Indeed, re-call of operative risks discussed at the time of consent are appreciably lower following emergency surgery.2 Psychological disorders should be considered during the consent process, with consent obtained as appropriate depending on the patient’s capacity, with formal psychiatric input required in complex cases. Clearly, the timescale in the emergency setting is not ideal for such cases, and undiagnosed psychological disorders may be missed. We report a case of a recently bereaved elderly lady admitted on the acute surgical take, critically unwell, requiring emergency surgery. Following discussion regarding the nature of the planned operation and associated risks, she was happy to consent for surgery. However, postoperatively, it transpired that she had signed the consent form in the hope of dying intraoperatively. We have identified no other reports in the literature of a patient having consented to surgery in the belief it would lead to their death. CASE PRESENTATION An octogenarian was admitted with a 12 h history of constant abdominal pain and reported a 2-stone weight loss
following the death of her husband 6 weeks previously. Her past medical history included an open cholecystectomy for gallstones 40 years ago, and the recent commencement of citalopram and zopiclone. She lived in her own house caring for her learning-disabled son in his mid-forties. She volunteered a poor motivation to get out of bed and prepare food since her bereavement. Furthermore, she had lost three daughters to cancer, 30, 10 and 3 years previously, with her husband’s death being ‘the final straw’. She did not have a living will or advance decision to refuse treatment. She was alert and orientated; however, on examination, was tachycardic, hypotensive, and had a tender, irreducible incisional hernia in the right upper quadrant. Investigations demonstrated grossly elevated inflammatory markers with a white cell count of over 25 000 and dilated small bowel loops on abdominal radiogram. The diagnosis of small bowel obstruction secondary to the irreducible hernia was proposed and immediate treatment involved intravenous fluid resuscitation. Definitive treatment would require surgery. CASE MANAGEMENT Formal written consent for surgery was obtained by the consultant surgeon, with the planned procedure and potential complications discussed and documented on the standardised form in the presence of her learning-disabled son. Given her frailty and the critical nature of her presentation, the risk of operative ‘death’ was also discussed. Despite the high risk, the procedure was relatively uneventful with viable transverse colon identified within the hernia sac. The hernia contents were reduced, thus relieving the obstruction, and the defect repaired. CASE OUTCOME Her immediate postoperative course was satisfactory, however, on day 2, she declined oral fluids and when challenged,
Murray-Brown F, et al. BMJ Supportive & Palliative Care 2014;4:303–305. doi:10.1136/bmjspcare-2013-000600
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Case report categorically refused all food and drink. Despite inadequate mobility she requested to go home to die on postoperative day 5. She subsequently declined all medical treatment including observations, haematological investigations, cannulation and nasogastric feeding. Furthermore, she declined chaplain visits. Psychiatric evaluation was performed by an elderly care physician, psychiatric nurse and liaison psychiatrist. She admitted to consenting to surgery in the belief that she would not survive the operation, and now wanted to return home to die. This belief was confirmed by her sister, although it had been concealed from her sister preoperatively. Psychiatric review did not diagnose depression, and she retained mental capacity to accept or refuse treatment and, therefore, could not be detained under the Mental Health Act. She rapidly deteriorated, becoming semiconscious and agitated, was transferred to a side room and received palliative support. She was clearly dying and was not fit enough to make the ambulance journey to the local hospice. In view of her now reduced capacity, a syringe driver containing oxycodone 2.5 mg and midazolam 5 mg over 24 h was commenced in her best interests to alleviate symptoms only. She died peacefully later that evening. CONCLUSIONS This case highlights two important issues. First, it is clear that the process of consent for emergency patients may be inadequate, particularly given complex psychological issues, such as that described in this case. Variation in interpretation of risk has been reported, with older patients often anticipating higher probabilities of negative outcomes.3 Furthermore, the probability associated with rare complications may be influenced by experience, such as family bereavement. Much work has focussed upon streamlining and improving the process of consent for surgery or invasive interventions, with a Cochrane review1 of specific interventions used to supplement this process published in 2013. This review included published work on a variety of aids (audiorecorded information, decision aids, interactive multimedia, structured consent, slide shows and question prompt sheets) and concluded that any aid will generally increase the patients’ perceived knowledge and understanding of the procedure. Indeed, these aids increased both immediate and long-term knowledge (15 days or more), suggesting a real impact on patients’ understanding. However, there were limitations; the mixed-age range used in most studies precluded subgroup analysis of the elderly patients. Also, this work focused upon elective patients, and the authors noted that consent as a process may be more challenging for emergency procedures. Previous work by Jefford and Tattersall4 commented that provision of complex information can be more difficult when caring for an emergency patient, particularly if the clinician believes the information may add to the patient’s stress. In our case, the patient had overestimated her risk of operative death.
304
It is uncertain whether she misinterpreted the information conveyed during the consent process, or had personal experience of relatives dying during surgery. Moreover, it is almost certain that without surgical intervention she would have died as a result of her obstruction. This suggests that she did not fully understand the given information, as, should she have wished to die, declining surgery would have been a better option. Second, despite our patient not dying during surgery, she effectively brought about her own demise by depriving herself of food, fluids, medical treatment and nursing care. We therefore draw attention to the fact that bereavement, particularly the loss of a spouse, can seriously affect mood. Reduced motivation for activities of daily living, such as cooking and eating, are often noted following bereavement of a spouse.5 This can result in malnutrition, reduced quality of life, and in some instances, premature or increased morbidity and mortality. Despite our patient expressing her low mood at admission clerking, the nature of her critical illness did not allow time for full psychiatric evaluation as she was at high risk of succumbing to her biological disease. Improved awareness of these issues among junior doctors may be of benefit, as early postoperative psychiatric support could be sought. However, Burns et al6 evaluated two methods (weekly psychiatric nurse assessments or psychologist-led cognitive behavioural therapy sessions) to treat or prevent depression, respectively, in elderly patients following hip fracture surgery. No significant benefits were observed in terms of depression rate, pain control or functional outcomes.6 It is, therefore, unlikely that earlier intervention would have altered outcome in this case, although unwanted surgery and postoperative treatment may have been avoided, and it may have been possible to allow her to return home to die with palliative care support.
Learning points ▸ Established psychological factors identified at admission clerking should be acted upon as soon as possible following life-saving treatment. ▸ All reasonable efforts must be made to ensure that emergency patients fully understand the indications for surgery, the risks involved (including an estimation of probability), the alternative treatment options, and the sequelae of declining surgery during the consent process. ▸ Following emergency treatment, early psychiatric, psychosocial and spiritual input should be sought, if indicated, to formally assess capacity, assess hopes and fears, and instigate treatment as required. ▸ Dying patients should be referred without delay to the palliative care team for symptom control, and to address logistics, such as support to return home if appropriate.
Murray-Brown F, et al. BMJ Supportive & Palliative Care 2014;4:303–305. doi:10.1136/bmjspcare-2013-000600
Downloaded from http://spcare.bmj.com/ on July 12, 2015 - Published by group.bmj.com
Case report Contributors None required. Competing interests None. Patient consent Obtained. Ethics approval This is a case report of a deceased patient. It is not research, and therefore, no ethical approval is required. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 Kinnersley P, Phillips K, Savage K, et al. Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. Cochrane Database Syst Rev 2013;7:CD009445.
2 Akkad A, Jackson C, Kenyon S, et al. Informed consent for elective and emergency surgery: questionnaire study. BJOG 2004;111/10:1133–8. 3 Mazur DJ, Merz JF. How age, outcome severity, and scale influence general medicine clinic patients’ interpretations of verbal probability terms. J Gen Intern Med 1994;9:268–7. 4 Jefford M, Tattersall MH. Informing and involving cancer patients in their own care. Lancet Oncol 2002;3:629–37. 5 McIntosh WA, Shifflett PA. Influence of social support systems on dietary intake of the elderly. Journal of Nutrition for the Elderly 1984;4:5–18. 6 Burns A, Banerjee S, Morris J, et al. Treatment and Prevention of depression after surgery for hip fracture in older people: randomised, controlled trials. J Am Geriatr Soc 2006;55:75–80.
Murray-Brown F, et al. BMJ Supportive & Palliative Care 2014;4:303–305. doi:10.1136/bmjspcare-2013-000600
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Downloaded from http://spcare.bmj.com/ on July 12, 2015 - Published by group.bmj.com
A morbid reason for consent Fay Murray-Brown and Llion Davies BMJ Support Palliat Care 2014 4: 303-305 originally published online March 20, 2014
doi: 10.1136/bmjspcare-2013-000600 Updated information and services can be found at: http://spcare.bmj.com/content/4/3/303
These include:
References Email alerting service
This article cites 6 articles, 0 of which you can access for free at: http://spcare.bmj.com/content/4/3/303#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Case report
A morbid reason for consent Fay Murray-Brown,1 Llion Davies2
1
Department of Palliative Medicine, Derriford Hospital, Plymouth, Devon, UK 2 Department of General Surgery, University Hospital of Wales, Cardiff, UK Correspondence to Dr Fay Murray-Brown, Palliative Medicine, Derriford Hospital, Derriford Road, Plymouth, PL6 8DH, UK; [email protected] Received 27 September 2013 Revised 7 February 2014 Accepted 28 February 2014 Published Online First 20 March 2014
To cite: Murray-Brown F, Davies L. BMJ Supportive & Palliative Care 2014;4: 303–305.
ABSTRACT We report the case of a recently bereaved elderly lady admitted on the acute surgical take who gave consent for emergency surgery in the hope of dying intraoperatively. To her dismay she survived and, thereafter, refused all food and medical intervention leading to her death 15 days later. This case highlights concerns regarding both the process of consent following emergency admission and failure to identify a vulnerable patient’s wishes.
BACKGROUND Informed consent prior to surgery is an integral part of modern clinical practice, usually considered a process,1 that starts at initial outpatient consultation for elective patients. However, this ideal scenario cannot be replicated for emergency admissions, as on-call surgeons have limited time, and delaying surgery may result in poorer patient outcomes. Indeed, re-call of operative risks discussed at the time of consent are appreciably lower following emergency surgery.2 Psychological disorders should be considered during the consent process, with consent obtained as appropriate depending on the patient’s capacity, with formal psychiatric input required in complex cases. Clearly, the timescale in the emergency setting is not ideal for such cases, and undiagnosed psychological disorders may be missed. We report a case of a recently bereaved elderly lady admitted on the acute surgical take, critically unwell, requiring emergency surgery. Following discussion regarding the nature of the planned operation and associated risks, she was happy to consent for surgery. However, postoperatively, it transpired that she had signed the consent form in the hope of dying intraoperatively. We have identified no other reports in the literature of a patient having consented to surgery in the belief it would lead to their death. CASE PRESENTATION An octogenarian was admitted with a 12 h history of constant abdominal pain and reported a 2-stone weight loss
following the death of her husband 6 weeks previously. Her past medical history included an open cholecystectomy for gallstones 40 years ago, and the recent commencement of citalopram and zopiclone. She lived in her own house caring for her learning-disabled son in his mid-forties. She volunteered a poor motivation to get out of bed and prepare food since her bereavement. Furthermore, she had lost three daughters to cancer, 30, 10 and 3 years previously, with her husband’s death being ‘the final straw’. She did not have a living will or advance decision to refuse treatment. She was alert and orientated; however, on examination, was tachycardic, hypotensive, and had a tender, irreducible incisional hernia in the right upper quadrant. Investigations demonstrated grossly elevated inflammatory markers with a white cell count of over 25 000 and dilated small bowel loops on abdominal radiogram. The diagnosis of small bowel obstruction secondary to the irreducible hernia was proposed and immediate treatment involved intravenous fluid resuscitation. Definitive treatment would require surgery. CASE MANAGEMENT Formal written consent for surgery was obtained by the consultant surgeon, with the planned procedure and potential complications discussed and documented on the standardised form in the presence of her learning-disabled son. Given her frailty and the critical nature of her presentation, the risk of operative ‘death’ was also discussed. Despite the high risk, the procedure was relatively uneventful with viable transverse colon identified within the hernia sac. The hernia contents were reduced, thus relieving the obstruction, and the defect repaired. CASE OUTCOME Her immediate postoperative course was satisfactory, however, on day 2, she declined oral fluids and when challenged,
Murray-Brown F, et al. BMJ Supportive & Palliative Care 2014;4:303–305. doi:10.1136/bmjspcare-2013-000600
303
Downloaded from http://spcare.bmj.com/ on July 12, 2015 - Published by group.bmj.com
Case report categorically refused all food and drink. Despite inadequate mobility she requested to go home to die on postoperative day 5. She subsequently declined all medical treatment including observations, haematological investigations, cannulation and nasogastric feeding. Furthermore, she declined chaplain visits. Psychiatric evaluation was performed by an elderly care physician, psychiatric nurse and liaison psychiatrist. She admitted to consenting to surgery in the belief that she would not survive the operation, and now wanted to return home to die. This belief was confirmed by her sister, although it had been concealed from her sister preoperatively. Psychiatric review did not diagnose depression, and she retained mental capacity to accept or refuse treatment and, therefore, could not be detained under the Mental Health Act. She rapidly deteriorated, becoming semiconscious and agitated, was transferred to a side room and received palliative support. She was clearly dying and was not fit enough to make the ambulance journey to the local hospice. In view of her now reduced capacity, a syringe driver containing oxycodone 2.5 mg and midazolam 5 mg over 24 h was commenced in her best interests to alleviate symptoms only. She died peacefully later that evening. CONCLUSIONS This case highlights two important issues. First, it is clear that the process of consent for emergency patients may be inadequate, particularly given complex psychological issues, such as that described in this case. Variation in interpretation of risk has been reported, with older patients often anticipating higher probabilities of negative outcomes.3 Furthermore, the probability associated with rare complications may be influenced by experience, such as family bereavement. Much work has focussed upon streamlining and improving the process of consent for surgery or invasive interventions, with a Cochrane review1 of specific interventions used to supplement this process published in 2013. This review included published work on a variety of aids (audiorecorded information, decision aids, interactive multimedia, structured consent, slide shows and question prompt sheets) and concluded that any aid will generally increase the patients’ perceived knowledge and understanding of the procedure. Indeed, these aids increased both immediate and long-term knowledge (15 days or more), suggesting a real impact on patients’ understanding. However, there were limitations; the mixed-age range used in most studies precluded subgroup analysis of the elderly patients. Also, this work focused upon elective patients, and the authors noted that consent as a process may be more challenging for emergency procedures. Previous work by Jefford and Tattersall4 commented that provision of complex information can be more difficult when caring for an emergency patient, particularly if the clinician believes the information may add to the patient’s stress. In our case, the patient had overestimated her risk of operative death.
304
It is uncertain whether she misinterpreted the information conveyed during the consent process, or had personal experience of relatives dying during surgery. Moreover, it is almost certain that without surgical intervention she would have died as a result of her obstruction. This suggests that she did not fully understand the given information, as, should she have wished to die, declining surgery would have been a better option. Second, despite our patient not dying during surgery, she effectively brought about her own demise by depriving herself of food, fluids, medical treatment and nursing care. We therefore draw attention to the fact that bereavement, particularly the loss of a spouse, can seriously affect mood. Reduced motivation for activities of daily living, such as cooking and eating, are often noted following bereavement of a spouse.5 This can result in malnutrition, reduced quality of life, and in some instances, premature or increased morbidity and mortality. Despite our patient expressing her low mood at admission clerking, the nature of her critical illness did not allow time for full psychiatric evaluation as she was at high risk of succumbing to her biological disease. Improved awareness of these issues among junior doctors may be of benefit, as early postoperative psychiatric support could be sought. However, Burns et al6 evaluated two methods (weekly psychiatric nurse assessments or psychologist-led cognitive behavioural therapy sessions) to treat or prevent depression, respectively, in elderly patients following hip fracture surgery. No significant benefits were observed in terms of depression rate, pain control or functional outcomes.6 It is, therefore, unlikely that earlier intervention would have altered outcome in this case, although unwanted surgery and postoperative treatment may have been avoided, and it may have been possible to allow her to return home to die with palliative care support.
Learning points ▸ Established psychological factors identified at admission clerking should be acted upon as soon as possible following life-saving treatment. ▸ All reasonable efforts must be made to ensure that emergency patients fully understand the indications for surgery, the risks involved (including an estimation of probability), the alternative treatment options, and the sequelae of declining surgery during the consent process. ▸ Following emergency treatment, early psychiatric, psychosocial and spiritual input should be sought, if indicated, to formally assess capacity, assess hopes and fears, and instigate treatment as required. ▸ Dying patients should be referred without delay to the palliative care team for symptom control, and to address logistics, such as support to return home if appropriate.
Murray-Brown F, et al. BMJ Supportive & Palliative Care 2014;4:303–305. doi:10.1136/bmjspcare-2013-000600
Downloaded from http://spcare.bmj.com/ on July 12, 2015 - Published by group.bmj.com
Case report Contributors None required. Competing interests None. Patient consent Obtained. Ethics approval This is a case report of a deceased patient. It is not research, and therefore, no ethical approval is required. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 Kinnersley P, Phillips K, Savage K, et al. Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. Cochrane Database Syst Rev 2013;7:CD009445.
2 Akkad A, Jackson C, Kenyon S, et al. Informed consent for elective and emergency surgery: questionnaire study. BJOG 2004;111/10:1133–8. 3 Mazur DJ, Merz JF. How age, outcome severity, and scale influence general medicine clinic patients’ interpretations of verbal probability terms. J Gen Intern Med 1994;9:268–7. 4 Jefford M, Tattersall MH. Informing and involving cancer patients in their own care. Lancet Oncol 2002;3:629–37. 5 McIntosh WA, Shifflett PA. Influence of social support systems on dietary intake of the elderly. Journal of Nutrition for the Elderly 1984;4:5–18. 6 Burns A, Banerjee S, Morris J, et al. Treatment and Prevention of depression after surgery for hip fracture in older people: randomised, controlled trials. J Am Geriatr Soc 2006;55:75–80.
Murray-Brown F, et al. BMJ Supportive & Palliative Care 2014;4:303–305. doi:10.1136/bmjspcare-2013-000600
305
Downloaded from http://spcare.bmj.com/ on July 12, 2015 - Published by group.bmj.com
A morbid reason for consent Fay Murray-Brown and Llion Davies BMJ Support Palliat Care 2014 4: 303-305 originally published online March 20, 2014
doi: 10.1136/bmjspcare-2013-000600 Updated information and services can be found at: http://spcare.bmj.com/content/4/3/303
These include:
References Email alerting service
This article cites 6 articles, 0 of which you can access for free at: http://spcare.bmj.com/content/4/3/303#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
