Indexing Title:
HTURINGAN’s Medical Anecdotal Report [05-01]

MAR Title:  What to do?

 Date of Medical Observation: 15 December 1999

 Narration:

 It was my last month as a first year resident, I couldn’t believe how I lasted 11 months of every other day duty, being a first line resident at the E.R., decked with most of the emergency operations the bulk of which were appendectomies lasting up to the next sunrise.  Post duty status was not better, ward work and manning the O.P.D. and admitting elective patients in the morning.  We were also in charge of the reporting the weekly audits and MSPRs.  One of the problems identified was the lack of autopsy cases of the hospital that might affect the accreditations of pathology and surgery.  Reporting then was very different, hospital and department concerns were sometimes merged since the acting chairman was the acting hospital director as well.  We were given a directive that all mortalities will be subjected to autopsy and if certain problems arise, as last resort such cases will be brought to his attention.

 At 6:30 pm a code was sounded and I performed resuscitation however efforts were futile and the patient was pronounced dead after 30 minutes.  I wrote the usual orders to the chart, the conduct of the resuscitation up to the time of demise, post mortem care, and order to secure consent for autopsy.  I proceeded to explain the protocol to the husband that for completion of the death certificate as much as possible it was encouraged to have an autopsy granted by the nearest of kin to ascertain and verify the cause of death.  Admitting diagnosis was gastric cancer stage IV.  The husband after an extensive explanation would not accede since this was against their religion.  I understood his reasons and informed him that the only thing I can do is to let him talk to my senior resident to explain his plight.  My team captain and later my chief resident talked to him to no avail.  The director-chair was informed of the case and personally tried to convince the husband. Finally at 12 midnight he conceded to a partial autopsy.  I later learned that he claimed that he was allegedly promised that the procedure would only entail a mini laparotomy for tumor biopsy.  I also learnt that partial autopsy meant thoracoabdominal exploration while total would include a craniectomy.  For some reason he was allowed by a med tech intern inside the autopsy room he was so angry because of the “desecration”.  The organs were returned and the husband pacified. 

 Or so it seemed until we received a letter from the Commission On Human Rights were in an administrative case was filed against all the surgical residents who talked to the husband, including the pathologist who performed the autopsy and the hospital director-department chairman for alleged grave misconduct, grave abuse of authority and malpractice after an affidavit was filed citing that a second autopsy was done by the commission wherein the kidneys were noted to be missing and that the meaning of partial autopsy was not explained clearly to the complainant, then later the case was handed over to the Professional Regulation Commission for gross negligence, incompetence and dishonorable conduct.  Lastly a criminal case was also filed to the Metropolitan Trial Court for reckless imprudence resulting to homicide. I’m now a criminal?! It was so surreal, like a story in a novel, a roller coaster you didn’t know you got in to, marred so early in my surgical life. 

 After 6 years the horror was finally over, all cases were one by one dismissed.

 Insights (physical, PSYCOSOCIAL, ETHICAL) ,Discovery, Stimulus, REINFORCEMENT:

 What do you do when you empathize and agree with the patient’s judgement  or decision and yet protocol dictates you to adhere to a certain policy of your hospital that is opposite to the wishes of the patient?

 A consent formed was duly signed by the complainant for the autopsy written in the vernacular and English explaining the procedure.  This saved us from the accusation that this was not explained to him in detail.  However, I personally felt that with his emotional state he truly neither understood the verbal explanation nor read the consent form as he should have.  Because of the shallowness of the grounds it was made to appear that we were responsible for the alleged missing kidneys, no surgical residents were present during the autopsy.  The truth was that he was angry and regretted his decision for giving consent to the performance of the autopsy after seeing the organs of his wife and wanted to lash back to all those doctors that convinced him to accede. He probably felt pushed to the wall, he was persuaded to do something he did not want to do in the first place.    

 I did not leave the experience unscathed, I pitied him and yet I was angry with the situation I found myself into, I followed protocol, I did nothing wrong, the time spent attending the hearings every month, the emotional exhaustion… and yet I feel so lucky I did not go through it alone my senior resident and chief resident was with me and I was comforted, city legal took care of our legal paper work which cost considerably less had we hired a private lawyer.

 I believe as doctors we have no right to take away the right of the patient to choose, even in death.  Even when we feel that what we wanted is for the best, we have no right to make the decision for them or give undue influence to sway their decision towards our own opinion and judgement.