Often a major part of a doctors job is making decisions – ranging from small ones like choice of antibiotics to big ones like DNR. Often it's the decision of the patient and family, but needing guidance of the attending doctor, who is expected to know the best. When all goes down well – good. But what when the parties have a difference of opinion and some problems crops up. such as in situations where, even after proper guidance and counseling on the physicians behalf, if the family chooses to make a decision in untoward consequences, does the doctor not share any responsibility whatsoever?
Following is one such is incident, which made me ponder – where do you draw the line – of who takes the blame?
We had a patient, 21 year old college kid, Punit, a couple of months back. He was referred to us from our sister concern hospital in interior Maharashtra, which was basically a secondary care centre. He presented with persistent fever since 2 weeks, high grade without chills and persistent low Total leukocyte counts. Also had history of loss of weights of over 3-4 kg in the past 3 months, but a normal appetite. No other significant history available.
On clinical examination - He was of slight built, vitally stable, with unremarkable findings on Respiratory and cardiovascular system examinations. He had however mild hepato-splenomegaly on per abdomen, with 3 firm, non tender, palpable cervical lymph nodes. No other palpable nodes anywhere else. Other than the fact that he had the mild toxic look of a febrile patient, he seemed fine.
On admission, his Total leukocyte counts were 1700/mm3, with Hemoglobin of 8.7 gm % and Platelet count of 1.25 lacks/mm3. His LFTS were deranged with Total Bili of 2.4 mg%, with a direct fraction of 0.9 mg%, ALT/AST of 56/79 IU/L and ESR – 123 mm. His Widal titers were 1:360 for Typhi H. He was started on broad spectrum antibiotics with anti-malarial cover with our area being pretty much of an endemic zone for malaria.
His Chest X ray showed enlarged hilar lymph nodes and abdominal USG picked up LNs as well.
Initially he seemed to be responding to our treatment with drop in the fever range and slight increase in the TLC to 2100 /mm3. However a couple of days later it again dropped back to 1500/mm3. He was already into Day 5 of antibiotics here. His tests for Dengue, Leptospirosis, hepatitis, blood cultures came back negative. But the fever persisted, despite change and trial of different antibiotics. An FNAC from his cervical node came back inconclusive as well.
We decided to go ahead with a CT of the abdomen and Thorax with contrast, which revealed discrete sub-centimeter LNs in the thorax and abdomen, occasionally matted but essentially all of them non-necrotic. Sr. ACE levels were normal.
DDs came down to either Koch's which could explain all of his symptoms and signs OR Lympho-reticular malignancy, which could explain all of his symptoms, and signs as well. Since Tuberculosis is endemic in India, we immediately started him on an AKT regimen with Streptomycin, Ethambutol and Ofloxacin. We had to avoid the first line drugs – Rifampicin, Isoniazid and Pyrazinamide in view of his LFTs, which had further deteriorated over the week.
Lymphoreticular malignancy was weighing heavily on my mind and I tried talking my attending into doing a Bone marrow aspiration. If it turned out normal well, we at least tried. But she being an old timer of sorts was not so keen on it, saying a trial of AKT ought to put us in a better know how. The debate continued on a daily basis for 2-3 days and finally she relented.
Miraculously however within 48 hours of starting AKT, Punit improved…. Dramatically. His fevers disappeared, his counts came up to 3600 /mm3. He looked and felt much better and also his nodes started disappearing. So AKT it was. We continued him on AKT with persistent improved responses, and in a week's time he was pretty much out of it. Everyone rejoiced.
But not for me the joy of a battle somewhat-easily-won. I harbored misgivings about not having a tissue diagnosis. Well in a place like India, where every 7th or 8th person had or will have Koch's somewhere in the lifetime, with clinical diagnoses of Tuberculosis – pulmonary and extra-pulmonary, being made a dozen times in our hospital itself on a daily basis, the 'Trial of AKT' concept is more prevalent than pursuing tissue diagnosis as the international textbooks say. Tuberculosis figures as a top DD in pretty much all cases of PUOs or Pyrexia of Unknown origin.
Therefore, Trial of AKT it was for Punit…
However, I convinced my attending for tissue diagnosis. Since his counts had picked up and stayed up, a bone marrow was ruled out. His palpable lymph nodes had disappeared so a LN biopsy was out the window. The only thing left was to do either a CT guided or a Transbronchial Needle aspiration cytology (TBNA). Now came the part of convincing the parents.
His parents were working class people, definitely not uninformed but were not exactly intellectual either. And the boy himself was an engineering student. So we sat all of them down for a heart to heart on the further plan. We or rather my attending spelled it out as explicitly as she could, concluding that even though the AKT seemed to be working for him, Punit might also be having some other occult disease that was getting masked and we needed to seek it out. Then came the pros and cons of the purported procedures, and the risks involved in them. They heard us out, we answered all their questions patiently. The conversation seemed well balanced back then, but in retrospect… well… I'll come to that later.
We gave them a day to think about it. Meanwhile health wise he was doing really well, his LFTs had improved considerably and he was stared on low doses of Rifampicin and INH as well. He was happy, his parents were relieved. Somehow our little chat about an alternate diagnosis didn't seem to weigh as much on their minds. Apparently they even called around and took a second opinion with their family physician before deciding to defer the CT LN biopsy for the present. I would like to mention here that financial constraints were nonexistent in this equation as all charges were being paid for the by the government organization that ran the hospital and employed the father.
Even though I am the chief resident here, I am not allowed to cross the Attending and speak to the relatives after all the pertinent decisions have been made, and I am ok with that. So his AKT was continued and he was discharged, sent back home and asked to follow up after a couple of weeks. All was well…
Till a month and a half later…
He came back to us, as a defaulter. He had stopped his meds since about a week and his fevers came back, as did his Lymph nodes. Apparently Punit had taken up some sports activity which made him miss his meds and his parents had not made a note of it. So back he was in exactly the same condition as last times. Except that this time his Total Leukocyte counts were 1300, his Hemoglobin was 6.6 gm% and his Platelet count was 78000/mm3 – he was pancytopenic. His temperatures were off the charts and his Lymph nodes were more in number and distributions. This time even though we put him back on his AKT, the signs persisted.
No waiting around this time, we went ahead with a bone marrow and open Cervical LN biopsy. Bone marrow was somewhat unremarkable except for a decrease in all cell lines. His LN biopsy however showed typical Reed – Sternberg's cells…
Hodgkin's…
DAMN….
AKT was stopped and he was referred to Tata Memorial Cancer hospital for further work up.
There was of course one more conversation with the parents, explaining this new turn, a conversation I chose not to be a part of.
It hounded me, a young boy, Hodgkin's lymphoma. So many questions…
Was the delay in diagnosis going to cost us bad? What would have happened had he not defaulted on his medication and the symptoms had been masked for another few months. Should we have insisted that the parents do the biopsy? Should I have gone ahead after the attending was through and talk some sense into the parents and Punit himself? Should we have stressed on the details of the alternated diagnosis while talking to the parents the first time around, in essence scaring them or drilling fear into their heads about the mortal nature of what we were suspecting? May be the doctor should be given sole responsibility to make such decisions, would that have avoided this situation? In retrospect all of these questions were valid, but unanswerable.
Who's fault is it? Who should take the blame if the delay in diagnosis makes a dent in his treatment options? Is the current system of informed decision making as good as it is made to sound? Or is just a roundabout way to split the blame with the patient party when things go wrong?
Even if say, it was entirely the decision of the Punit and his family… can I as a doctor sleep comfortably at night, knowing that my patients decision could cost him his life.
Maybe it's ok, if it's a situation where it's a terminal disorder and the patient does not want to suffer anymore and chooses to discontinue or deny treatment. That would be understandable. But Punit's situation where time is muscle… should we as doctors let the patients and family make such mistakes on the name of informed consent? Is there no way around it?
I was in a turmoil for a whole week after this… guessing and second guessing myself. My attending, focused on the fact that we had been explicit as possible in the discussion with the parents, when they had chose to defer the biopsy, (read – a lawsuit was out of question).
Don't know how to end this tale… well, Punit has been started on Chemo, and is being planned for Anti CD 20 therapy. His future remains dark.
Following is one such is incident, which made me ponder – where do you draw the line – of who takes the blame?
We had a patient, 21 year old college kid, Punit, a couple of months back. He was referred to us from our sister concern hospital in interior Maharashtra, which was basically a secondary care centre. He presented with persistent fever since 2 weeks, high grade without chills and persistent low Total leukocyte counts. Also had history of loss of weights of over 3-4 kg in the past 3 months, but a normal appetite. No other significant history available.
On clinical examination - He was of slight built, vitally stable, with unremarkable findings on Respiratory and cardiovascular system examinations. He had however mild hepato-splenomegaly on per abdomen, with 3 firm, non tender, palpable cervical lymph nodes. No other palpable nodes anywhere else. Other than the fact that he had the mild toxic look of a febrile patient, he seemed fine.
On admission, his Total leukocyte counts were 1700/mm3, with Hemoglobin of 8.7 gm % and Platelet count of 1.25 lacks/mm3. His LFTS were deranged with Total Bili of 2.4 mg%, with a direct fraction of 0.9 mg%, ALT/AST of 56/79 IU/L and ESR – 123 mm. His Widal titers were 1:360 for Typhi H. He was started on broad spectrum antibiotics with anti-malarial cover with our area being pretty much of an endemic zone for malaria.
His Chest X ray showed enlarged hilar lymph nodes and abdominal USG picked up LNs as well.
Initially he seemed to be responding to our treatment with drop in the fever range and slight increase in the TLC to 2100 /mm3. However a couple of days later it again dropped back to 1500/mm3. He was already into Day 5 of antibiotics here. His tests for Dengue, Leptospirosis, hepatitis, blood cultures came back negative. But the fever persisted, despite change and trial of different antibiotics. An FNAC from his cervical node came back inconclusive as well.
We decided to go ahead with a CT of the abdomen and Thorax with contrast, which revealed discrete sub-centimeter LNs in the thorax and abdomen, occasionally matted but essentially all of them non-necrotic. Sr. ACE levels were normal.
DDs came down to either Koch's which could explain all of his symptoms and signs OR Lympho-reticular malignancy, which could explain all of his symptoms, and signs as well. Since Tuberculosis is endemic in India, we immediately started him on an AKT regimen with Streptomycin, Ethambutol and Ofloxacin. We had to avoid the first line drugs – Rifampicin, Isoniazid and Pyrazinamide in view of his LFTs, which had further deteriorated over the week.
Lymphoreticular malignancy was weighing heavily on my mind and I tried talking my attending into doing a Bone marrow aspiration. If it turned out normal well, we at least tried. But she being an old timer of sorts was not so keen on it, saying a trial of AKT ought to put us in a better know how. The debate continued on a daily basis for 2-3 days and finally she relented.
Miraculously however within 48 hours of starting AKT, Punit improved…. Dramatically. His fevers disappeared, his counts came up to 3600 /mm3. He looked and felt much better and also his nodes started disappearing. So AKT it was. We continued him on AKT with persistent improved responses, and in a week's time he was pretty much out of it. Everyone rejoiced.
But not for me the joy of a battle somewhat-easily-won. I harbored misgivings about not having a tissue diagnosis. Well in a place like India, where every 7th or 8th person had or will have Koch's somewhere in the lifetime, with clinical diagnoses of Tuberculosis – pulmonary and extra-pulmonary, being made a dozen times in our hospital itself on a daily basis, the 'Trial of AKT' concept is more prevalent than pursuing tissue diagnosis as the international textbooks say. Tuberculosis figures as a top DD in pretty much all cases of PUOs or Pyrexia of Unknown origin.
Therefore, Trial of AKT it was for Punit…
However, I convinced my attending for tissue diagnosis. Since his counts had picked up and stayed up, a bone marrow was ruled out. His palpable lymph nodes had disappeared so a LN biopsy was out the window. The only thing left was to do either a CT guided or a Transbronchial Needle aspiration cytology (TBNA). Now came the part of convincing the parents.
His parents were working class people, definitely not uninformed but were not exactly intellectual either. And the boy himself was an engineering student. So we sat all of them down for a heart to heart on the further plan. We or rather my attending spelled it out as explicitly as she could, concluding that even though the AKT seemed to be working for him, Punit might also be having some other occult disease that was getting masked and we needed to seek it out. Then came the pros and cons of the purported procedures, and the risks involved in them. They heard us out, we answered all their questions patiently. The conversation seemed well balanced back then, but in retrospect… well… I'll come to that later.
We gave them a day to think about it. Meanwhile health wise he was doing really well, his LFTs had improved considerably and he was stared on low doses of Rifampicin and INH as well. He was happy, his parents were relieved. Somehow our little chat about an alternate diagnosis didn't seem to weigh as much on their minds. Apparently they even called around and took a second opinion with their family physician before deciding to defer the CT LN biopsy for the present. I would like to mention here that financial constraints were nonexistent in this equation as all charges were being paid for the by the government organization that ran the hospital and employed the father.
Even though I am the chief resident here, I am not allowed to cross the Attending and speak to the relatives after all the pertinent decisions have been made, and I am ok with that. So his AKT was continued and he was discharged, sent back home and asked to follow up after a couple of weeks. All was well…
Till a month and a half later…
He came back to us, as a defaulter. He had stopped his meds since about a week and his fevers came back, as did his Lymph nodes. Apparently Punit had taken up some sports activity which made him miss his meds and his parents had not made a note of it. So back he was in exactly the same condition as last times. Except that this time his Total Leukocyte counts were 1300, his Hemoglobin was 6.6 gm% and his Platelet count was 78000/mm3 – he was pancytopenic. His temperatures were off the charts and his Lymph nodes were more in number and distributions. This time even though we put him back on his AKT, the signs persisted.
No waiting around this time, we went ahead with a bone marrow and open Cervical LN biopsy. Bone marrow was somewhat unremarkable except for a decrease in all cell lines. His LN biopsy however showed typical Reed – Sternberg's cells…
Hodgkin's…
DAMN….
AKT was stopped and he was referred to Tata Memorial Cancer hospital for further work up.
There was of course one more conversation with the parents, explaining this new turn, a conversation I chose not to be a part of.
It hounded me, a young boy, Hodgkin's lymphoma. So many questions…
Was the delay in diagnosis going to cost us bad? What would have happened had he not defaulted on his medication and the symptoms had been masked for another few months. Should we have insisted that the parents do the biopsy? Should I have gone ahead after the attending was through and talk some sense into the parents and Punit himself? Should we have stressed on the details of the alternated diagnosis while talking to the parents the first time around, in essence scaring them or drilling fear into their heads about the mortal nature of what we were suspecting? May be the doctor should be given sole responsibility to make such decisions, would that have avoided this situation? In retrospect all of these questions were valid, but unanswerable.
Who's fault is it? Who should take the blame if the delay in diagnosis makes a dent in his treatment options? Is the current system of informed decision making as good as it is made to sound? Or is just a roundabout way to split the blame with the patient party when things go wrong?
Even if say, it was entirely the decision of the Punit and his family… can I as a doctor sleep comfortably at night, knowing that my patients decision could cost him his life.
Maybe it's ok, if it's a situation where it's a terminal disorder and the patient does not want to suffer anymore and chooses to discontinue or deny treatment. That would be understandable. But Punit's situation where time is muscle… should we as doctors let the patients and family make such mistakes on the name of informed consent? Is there no way around it?
I was in a turmoil for a whole week after this… guessing and second guessing myself. My attending, focused on the fact that we had been explicit as possible in the discussion with the parents, when they had chose to defer the biopsy, (read – a lawsuit was out of question).
Don't know how to end this tale… well, Punit has been started on Chemo, and is being planned for Anti CD 20 therapy. His future remains dark.