In her 5 years as a palliative care nurse, Lisa has experienced more death and ethical dilemmas than most do in a lifetime. Last month, she handled a case that highlights two complex points of conflict: one for herself, balancing conflicting duties as a nurse, and one for a surgeon, held to a bureaucratic practice that interferes with patient care.
A frail man in his late 80’s had a history of abdominal tumors and several previous heart procedures. His upcoming procedure, a TAVR (transcatheter aortic valve replacement) was a last resort. TAVRs are intended only for elderly patients in the direst conditions.
Lisa was consulted to help the patient make a home-care plan for after the surgery. During her first visit, she realized he was not likely to survive the procedure. He had stopped eating and drinking, he had difficulty breathing, and he had an enlarged abdominal tumor. The oncologist who evaluated him also recommended no surgery for a man in his condition, and estimated that he had one year to live.
Meanwhile, the surgeon had already moved forward with the surgery, performing the necessary preparatory procedures. The attending physician reassured the patient and family that this procedure was the best step forward.
Two days following the TAVR, the patient suffered intestinal necrosis, or a dead bowel. Even for healthy people, a dead bowel is a death sentence. The family withdrew care and moved him to Hospice. A few days later, he died.
Why did they perform a surgery that was so obviously risky?
First, a TAVR is the standard practice for elderly patients with few alternatives, and in this case, the patient had an even smaller chance of surviving chemotherapy for his tumors.
Second, the patient and the family wanted the surgery. According to his nurse, patients of his age and from his rural community tend to trust doctors deeply, and fully comply with their suggestions.
Third, the cardiac surgeon is required by Medicare to perform a certain number of these procedures annually, according to a cardiologist at the same hospital. The surgeon may have been pressured to approve the procedure despite the risk.
This case presents complex ethical dilemmas for multiple parties. Lisa wrestled balancing her roles as a care provider and a patient advocate. As a nurse, she would not have recommended the surgery, given the patient’s feeble condition. As a patient advocate, she had to support the patient’s and family’s decision to proceed with the surgery.
According to Lisa, palliative care workers frequently face this conflict, and currently, there is no official code of ethics or professional guidelines that they can consult.
The most alarming ethical dilemma in this case was imposed on the surgeon.
Medicare requires cardiac surgeons and cardiologists to perform 25 TAVRs per year to maintain proficiency, according to the National Coverage Determination by the Centers for Medicare and Medicaid Services. Otherwise, they may lose their ability to treat Medicare patients.
Additionally, hospitals must fill annual surgical quotas, which may have exerted institutional pressure on the surgeon.
These quotas endanger patient safety, and undermine surgeons’ medical expertise, as exemplified by this patient’s experience. Doctors should make medical decisions based solely on what is best for the patient. Any other factor is a distraction from quality care.
After years of training, surgeons and physicians know how to choose the best course of treatment. No bureaucratic policy should interfere with that process.
“We accelerated his death, as far as I am concerned,” says Lisa.