Friday, September 2, 2011

Above All Else, Hold Onto Your Integrity


In medicine there is an unwritten rule of professional conduct.  It states that the hospital attending is the only one who is supposed to go in and tell a patient their medical diagnosis and treatment.  Anyone else on the medical team is just supposed to pretend as though they don’t know anything until after the attending has discussed the diagnosis with the patient.  Usually this works out, but it can also lead to a breakdown in patient’s trusting their providers  and/or asking team members to lie to patients until the attending can have their discussion with them.  We as medical providers need to have integrity in everything we do, and that includes being truthful with our patients which helps them build trust in our capabilities.
I remember one such instance where I was asked to compromise my integrity.   It eventually led to me leaving this position in the bone marrow transplant unit and moving out of state to take another PA position.  As I have done in the past, I will continue to do in the future, and that is to hold onto my integrity.  I will always put my patient’s well-being ahead of myself and tell them the truth so as to allow them to trust me then, and in the future.


I was working in a bone marrow transplant unit at a major academic hospital, and as such was responsible for 5-6 patients every day.  I made rounds with the attending physician, wrote progress notes, ordered labs, radiology, called for consults, etc. 

I had been assigned an 18 year old patient who had acute myelogenous leukemia and was being admitted for an allogeneic bone marrow transplant, using her sister as her donor.  Cheryl was my patient all the way through her pre and immediate post-transplant period.  She was doing as expected by day 30 post-transplant and was therefore discharged.  Afterwards, she was followed in the out-patient clinic where I saw her and then checked her out with the attending physician. 

Cheryl was doing as expected until day 60 post-transplant.  That’s when I received a phone call from the in-patient attending telling me that she was being re-admitted due to her having a grand mal seizure at home. 

The first thing I thought of was she had relapsed with her leukemia.    She arrived by ambulance and was immediately brought up from the emergency room.  I was ready for her, I had written her admission orders and had my lumbar puncture kit ready with a consent form that she and her mother would have to sign. 

“Hi, Cheryl, I’ve been told what happened with you at home.  I know that you are thinking the same thing I am, as well as the attending physician is, and that is the issue of whether your leukemia is back.   For us to rule this out or in I have to do a lumbar puncture on you right now.  We have to get some spinal fluid down to the lab for them to look for any leukemia cells.”

“I know,” Cheryl said, her face reflecting the image of sadness.

“Okay, well then let me go over this consent form with you and then get the lumbar puncture done.”

“Sure.”

Consent form signed, lumbar puncture was quickly done and I sent the spinal fluid down to the laboratory for analysis.  Several hours later her cell count came back normal, as well as her glucose and protein levels.  But the spinal fluid results didn’t totally rule out a leukemia relapse.  She could have a negative spinal tap and still have leukemia.  The only way to rule this out was to do a cranial MRI and look for thickened nerve sheaths.  Her MRI was scheduled for the following morning.

I can only imagine Cheryl had a restless night trying to sleep.  Her mom was in the cot next to her.  First thing in the morning she was down in the MRI machine having her contrast MRI done. 

After rounds were done, our team headed down to visit with the neuro-radiologist to go over her results.  He quickly put the scans up for us to see.  To educate all of us, he went over the differences between T1 and T2 images.  Then he pointed out that Cheryl did not have any evidence of leukemia, no thickened nerve sheaths. 

Then he said,” what she did have was a difference in her uptake between T1 and T2, which he said was seen in patients who were having problems with cyclosporine.  Therefore she had cyclosporine related seizures. “

“What a relief,” I thought to myself.  “That’s easy to take care of, we just have to switch her immunosuppressant medications and her seizures will stop!”

The team finished looking at the other radiology reports we needed to see and then the attending said he would discuss what to change Cheryl over to with another attending and then be up to see her. 

I went back up to the floor and was busy writing my progress notes, when Cheryl’s nurse came to find me.  She told me that Cheryl was nauseated and vomiting and she needed an order for meds.  I got up and immediately went into Cheryl’s room. 

“Cheryl what’s going on, when did your nausea and vomiting start?”

Through dry heaves, Cheryl answered me, “about thirty minutes ago.”

 A quick scan of Cheryl’s teary demeanor, her tightly holding onto her mother’s hand, her mom hugging her daughter so tight it must have hurt, and Cheryl hugging the upchuck bucket, was all I needed to see.  Cheryl and her mom had worked themselves up into an anxious almost panicky mode of operation over whether she had relapsed.  I turned to her nurse standing in the room and gave her a verbal order for 1 mg of Ativan IV now. 

As I turned to leave the room, Cheryl asked me a direct question I couldn’t ignore. 

“I know you know, Sharon.  You have to tell me, is my leukemia back?”

I turned back around to Cheryl and took in a deep breath.  Quickly I thought to myself, “did I break the accepted professional medical code of conduct and tell her the truth?  Or do I somehow wiggle out of answering her question, and wait for the attending to show up to tell her, even though by now it was 4-5 hours after rounds had ended.  If I answered her with the truth, all of her anxiety and panic over a possible leukemia relapse would immediately dissipate into nothing.  But I knew withholding the truth would be mean and dishonest to her. “

I had to take the plunge and in so doing, hold onto my integrity. 

“Cheryl your MRI showed that your leukemia is not back.  It showed that you are having a problem with your cyclosporine medication and we have to switch you over to another immunosuppressant medication.  The attending will be up here to discuss it with you hopefully before too long.”

Hearing this, Cheryl and her mom turned to each other and hugged each other through their tears of relief. 

“Thank you, Sharon” was all Cheryl was able to mouth back to me. 

By then her nurse had left the room in an angry huff and immediately went across the hall to the head nurse’s office. 

I turned to leave the room to finish up my progress notes.  Only now it was me who had the upset stomach, I knew I hadn’t heard the last of what I had just done.  An hour later the attending finally did show up and go into her room to discuss the change of medications with her and her mom.  Thankfully Cheryl did just fine on her new medication and was sent home a day later to be followed up in the out-patient clinic.

As I was handing Cheryl her discharge orders, she said, “Sharon I heard what happened to you yesterday and I’m sorry about it.”

“Cheryl, what happens to me because of my discussion with you yesterday, is my concern.  What I would like to explain to you is why I did it.  You asked me a direct question that I couldn’t ignore.  You deserved an answer that was truthful and honest.  There was no reason for you to be in this room upchucking your stomach contents into the yellow bucket.  I could have lied to you, and told you that I didn’t know anything, when I did.  But then I would have compromised my integrity in the process.  And if you knew that I had lied to you, where would that have lead you in the future when you see me in clinic?  Would you have been able to totally trust what I told you then?  I doubt it.  You need to be able to trust your providers, you need to know that they are telling you the truth, even when it costs them to do so.  Otherwise the relationship that you need to have with your medical providers, which has to be built on trust, can too easily be shattered.  You need to know that when I see you in the clinic and advise you to do something, or change your medications, you can trust my word about it and do it.  Had I lied to you yesterday, the possibility of your compiling with your medical treatment program decreased.  I want you to understand that and know that I was looking out for your benefit yesterday, no matter what happens to me.  Understood?”

 “Yes, I understand and I want to then say ‘thank you’ for doing it.”

“You’re welcome, and I’ll see you next week in clinic, do well until then.”


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