Let no broken hip go unfixed: When a surgeon fails to communicate

She was 94-years old with advanced Alzheimer’s. She thought it was 1954 and asked if I wanted tea. Not a bad memory for someone in a hospital bed with a broken left hip.

She’d fallen at her assisted living facility. It was the second time in as many months. She’d broken her collarbone on the previous occasion.

Over the past year, she’d lost 30 pounds. This is natural in the progression of Alzheimer’s. But it’s upsetting to families all the same.

My patient was lucky. She’d lived to 94, and had supportive children who were involved in her care. Her son had long ago been designated as power-of-attorney for her health care. This meant officially that his decisions regarding her care were binding. She was not capable of making sound decisions, medical or otherwise.

The patient had been under the care of a geriatrician. His office chart told me that the option of hospice and palliative care had been discussed with the family. They were interested in learning more; the son had agreed that “Do Not Resuscitate” status was appropriate for his mother. Doing chest compressions on a frail 94 year-old is something none of us want to do.

The morning after her hospital admission for the broken hip, the medical intern called me with an ethical dilemma: “She’s DNR,” the intern explained. “She’s having intermittent VTach on the monitor, and I fear she won’t be stable enough to have the hip repaired. The family is open to the idea of hospice, but I don’t know whether to treat the arrhythmia or not.”

Elaine (not her real name) is one of our brightest interns. She’s thinking about going into geriatrics. Situations like this are in many ways the most meaningful for doctors. Too often we stress about minutiae at the expense of the big picture; helping guide a family and patient through a period of critical illness is of true service.

“Bearing witness is our most important role,” a mentor once taught me.

I came in to round with Elaine. We went immediately to the patient’s room. The son and one of his sisters were there supporting their mother.

In the bed I saw a pale, thin, older woman who appeared to be lying comfortably. I asked her if she was in pain. “Would you like some tea?” she asked.

I told her she didn’t look 94. She smiled. I told her she had a beautiful smile, and she smiled again.

We proceeded to discuss the medical issues with the patient’s son and daughter:

  • advanced dementia
  • weight loss
  • multiple falls
  • hip fracture
  • anemia
  • irregular, potentially unstable heart rhythm

“What would your mother want?” I asked them. “If she could decide for herself, what would her goals be?” Given her frailty, even with repairing the hip she’d never walk again.

Understandably, the concerns were about her suffering and feeling pain. At the moment, we were all in agreement that she looked comfortable. I broached the subject of not doing anything to treat the arrhythmia or the broken hip–of not putting the patient through surgery.

The son was clear. “She wouldn’t want surgery,” he told us. His sister agreed. Consensus! We would refer her to hospice. She’d live out her days in comfort, forgoing the indignities of further medicalization.

At that moment, the orthopedic nurse practitioner walked into the room, carrying a consent form. She approached the opposite side of the bed. Before she could launch into her speech, I cut her off. “The family has decided on hospice,” I informed her. I asked to speak with her outside.

“We’ve only not operated on two occasions that I can remember,” the nurse practitioner told me. Her comment unnerved me. Clearly we were deviating from standard operating procedure here. “If a hip’s broken, we fix it,” is what she was telling me.

She documented our conversation and the fact that the family had declined surgery in the chart.

I went back in the room. I asked the family if they had any more questions. Satisfied that we’d answered everything to the best of our abilities, I excused myself and Elaine. We thanked the son and daughter for their courage, and affirmed that I thought they were making the right decision to forgo surgery.

Outside the room, we debriefed about the encounter. I was very proud of Elaine’s poise in a difficult patient/family situation, and how well she reasoned through the multiple options. I told her that I admired her instinct to mitigate harm to the patient by not over-medicalizing the situation, as many would have done since it’s almost always the path of least resistance in the hospital.

Alas, we congratulated ourselves too soon.

The next morning I came in to round. The patient’s name was still on our list.

We went to her room. She wasn’t there. But the bed was missing, too.

After the fact.

“Did the patient in 1214 get transferred to hospice?” I asked to no one in particular outside her room.

“She’s in the OR,” said the ward clerk.

What the f*ck?

I was furious. A patient whose dying wish was to be made comfortable, at 94 with dementia, severe weight loss, who’d never walk again, had been “taken” to the operating room, possibly against her family’s wish to have her broken hip “pinned?”

How had this decision been made? Who’d made it? And why the fuck had nobody talked to me about it? As the attending physician, I was legally and ethically responsible for the care of the patient.

I called the OR. I got the surgeon on the phone. “This patient had an advance directive. Her son, who’s her power of attorney, wanted her to go to hospice. What’s she doing in the OR?”

“I’m just covering my colleague,” came the reply. “He consented her. I’m just going to “pin” her hip, not repair or replace it. Please clarify this with the family and let me know what they want to do–as soon as you can–she’s already on the table and the spinal’s been administered.”

Great. The train had not only left the station, it was already hurtling down the tracks. I did not appreciate the “covering” surgeon’s passivity. He was just doing what he’d been told. Hey, fella-how about taking some responsibility to clarify and verify things before cutting on anyone? Did it strike you as weird to take an emaciated, demented 94 year-old to the operating room?

Apparently not. Not at all. I remembered the nurse practitioner’s bizarre comment from the day before: “We’ve only not operated on a broken hip twice.” Is that because those patients were already dead?

I found the family in the surgical waiting area. Oddly, it was the patient’s other two daughters, not the power-of-attorney son and nurse daughter with whom I’d spoken the day before.

“Did you and your siblings consent to this procedure?” I asked them. “Yesterday your brother and sister told me that they wanted no further intervention; they wanted your mother to go to hospice to live out her remaining days in comfort.”

“Well, yes,” one of the daughters told me. “They told us it’s a minor operation and will just “stabilize” things before she goes to hospice. They warned us that she’d be in pain any time she moved, and we didn’t want that. Isn’t this the right thing to do?”

With all my soul I wanted to scream at her, “Let your poor mother die! Why on earth would you subject her to this ridiculous “operation” and spinal anesthesia? And what the fuck kind of surgeon comes by after the decision has been made and brainwashes a poor family into an unnecessary operation and doesn’t have the courtesy to discuss the “plan” with the attending physician?”

But I didn’t say that.

She needed my support. “Well, this is among the most difficult situation anyone ever faces,” I said. “There’s no right answer. For some people, NOT doing surgery would be the right decision. For others, a sense of fixing what’s broken will seem like the right course of action.”

I asked the two sisters if their brother and other sister had agreed with this. I was surprised that they weren’t there at the scene. Perhaps the power-of-attorney brother who’d made a resolute decision a day earlier based on what his mother would have wanted had changed his mind. Perhaps he’d felt guilty disagreeing with his sisters, and wanted consensus above all else. Perhaps it really was a “minor” procedure and the right course of action to mitigate the mother’s suffering.

But I’d seen her in her bed. She’d smiled at me. She’d discussed having tea. She wasn’t writhing uncomfortably or looking in distress.

I was angry. Had the consenting surgeon simply seen dollar signs? No broken hip goes unfixed? He’s a hammer and the patient was a nail?

Let me take the high road: Maybe he genuinely believed that pinning the patient’s hip would improve her quality of life in the days she had left. Maybe he had some evidence I’m unaware of that pinning hips in demented 94-year-old patients is the most efficacious plan of action. All bow down before the gods of evidence.

But he should have spoken with me. As a colleague. As a professional. As the one responsible for the patient’s care. Maybe he could have persuaded me that this was the right thing to do. Maybe he’d have even turned the tables and shown me that I was the one being inhumane. After all, how “right” is it to send a feeble old woman to die with a broken hip?

It’s too bad for all involved here that his thought process was not made transparent. He and I will clearly be having a conversation, likely with hospital administration in attendance, about what happened here. This is a conversation we should all be having.

John Schumann is an internal medicine physician who blogs at GlassHospital.  

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  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    If it was well documented in the chart that the son has power of attorney and is the legal health care surrogate and that he decided against surgery then the surgeon, his staff and the hospital including the anesthesiologist assaulted this woman. In our area, Hospice , if consulted, responds very quickly so I am surprised that they weren’t available to prevent this from happening. The fact that you told the nurse practitioner that the legal guardian with power of attorney had chosen comfort measures only should have been good enough to stop the process. The NP should be reported to your state Medical Nursing Board as should the surgeon, the anesthesiologist and the institution. This was a mistake but also a crime.

    • Suzi Q 38

      I agree. I don’t think doctors “call out” doctors when they should.
      It was not the surgeon’s business. Aren’t some HIPPA rules broken here within the hospital? (NP and surgeon?).

  • http://www.facebook.com/jackie.schneider.1426 Jackie Schneider

    Difficult decisions to make when a person is elderly and frail. My grandmother fell through the medical cracks in a nursing home. She was failing rapidly and they could not give her end of life comfort meds because orders had not been written, to our horror. They called the doctor who never responded in time, she died without any comfort meds.

    • Suzi Q 38

      Sorry this happened to your grandmother.

  • http://Meddebate.com/ Jamal Ross

    Interesting article. As a surgical trainee I have witnessed a similar situation.

  • http://www.facebook.com/stephen.rockower Stephen Rockower

    As an orthopaedic surgeon who has tried to do this both ways (with and without surgery), the most “caring” thing to do is to OPERATE. If she dies, she dies, but trying to care for an unfixed hip fracture is cruel and unusual punishment. It is a terrible way to die, often with bedsores etc, because no one want to hurt her by turning her. Fix the hip as quickly and as painlessly as possible, and then see what happens. I agree that “proper protocols” were not followed here as Dr, Reznick points out, but she needed to have the surgery.

    • Suzi Q 38

      She wan’t in pain, though doc.
      She was smiling and serving “tea” to everyone.
      I think that sometimes, hospitals and doctors like to bill a few more operations to the insurance or medicare before the patient dies.
      If I were the surgeon, I would not have “crossed the line” like that.
      It was NOT his or her patient.
      If it is found that the nurse solved this disagreement by calling in a surgeon instead of her boss, she should be reported and disciplined.
      She should have at least confronted the doctor to his face rather than set up a surgery contrary to his treatment instructions behind his back.

      The siblings called were probably 3rd or 4th on the list of family members to call. The first two were not called for obvious reasons.
      This is very “sneaky” and deliberate.

      People wonder why I would ask each medical professional (at the hospital) what they were doing for my relative at any given time. Sometimes they just wanted to be paid for the procedure, and it had nothing to do with whether or not the patient truly needed the procedure.

      • militarymedical

        Side note: why do you assume the nurse is a “she”? As irritating as assuming the doctor is always a “he.” (In this case, he clearly is a he.)

        • Suzi Q 38

          My bad, but you can look at the other posts of mine that refer to the nurse ans he/she, or simply NP.
          I must have gotten tired of being PC.
          So what if the NP was a he.

        • Suzi Q 38

          “Side note: why do you assume the nurse is a “she”? As irritating as assuming the doctor is always a “he.” (In this case, he clearly is a he.)”

          FYI, please read the article again. The nurse is a “she.”
          The doctor is a “he” in this case, unless females are named John.

      • karen3

        And this sneaky maneuver to bilk medicare of a couple thousands will probably result in permanent acrimony between the siblings. Really disgusting behavior.

        • Suzi Q 38

          The administration of the hospital probably will agree with the surgeon because he/she makes more money for the hospital. In this case, their services were not required, asked for, or needed. Scary.
          I am glad that this was written.
          I would definitely point out that I was the POA and that I was NOT called to help make this decision.
          I would ask for a meeting with a hospital representative, the surgeon, and the NP. i would demand some answers, I would show them my POA legal papers and my mother’s DNR order. If the admin did nothing, I would complain to the Joint Commission.
          I would view the surgery as an aggressive, bold move that was not authorized by the right family member in charge.

    • Suzi Q 38

      It all depends on how it was done.
      So the NP calls the surgeon, then gets approval from different family members and not from the son that has the POA?
      Then they tell the other siblings that this surgery is “better” and “needed??” I think that the surgeon is not very bright.
      Now, he may have to answer to administration.
      He should have placed a courtesy call and/gotten clearance for surgery from the patient’s physician.
      i needed spine surgery, but I could not do it without clearance from the neurologists first.
      I guess that surgeon does not want any referrals from the author.

    • http://www.facebook.com/profile.php?id=100000077801405 Jay B. Ham

      As a hospitalist, I respectfully disagree that caring for an unfixed is cruel and unusual. I’ve placed numerous elderly, emaciated, demented patients on hospice and foregone surgery. They invariably die within days to a few weeks. I have yet to have a family tell me that they wished they had “fixed” the hip. Pain meds cover a host of ills, particularly in patients who are already dying from a terminal disease which this article emblemizes.
      Certainly some patients will benefit by “fixing” the hip. The oft accompanying delirium can cause some to be very aggressive and impulsive, they will cause themselves much agony and can usually be identified quickly. Level of physical activity prior to the injury also helps distinguish surgical from non-surgical candidates.

  • drd

    so what ended up happening?

  • Simon Whyte

    As an anaesthetist (or anaesthesiologist as I presume this is a US hospital) & as Chair of our hospital’s Quality of Care committee, with responsibility for sanctioning critical incident reviews, I am trying to think how I would handle this event. Dr Reznick’s response is instinctively agreeable & I’m sure a critical review of the system might well yield performance-related issues – but this has to start with a system-based review. This lady did not get into the OR without clearing a few metaphorical hurdles – not the least of which would have been an anaesthesia assessment – & unless there was a conspiracy of criminal proportions, this smacks of holes aligning in Swiss cheese. Communication failures are almost universally a feature of critical incidents & this one will be no exception. But before we assume that everyone involved in getting the patient to the OR was criminally negligent &/or guilty of assault (which they may turn out to be), I hope that due process exists at this institution to start this critical event review with a systems perspective.

    • Suzi Q 38

      The anesthesiologist???? What a conflict of interest.
      The anesthesiologist would love another procedure to bill the insurance for. The only person that should have been called was the primary doctor in charge.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I certainly hope this is a fictional case used for training purposes and not an actual patient. As I said in my earlier post the wishes of the power of attorney, who presumably represents the patients wishes should have taken priority. The question of the whether pinning the hip and gettting the patient up and ambulating to avoid the pneumonia bedsore situation which most likely would develop if no surgery is performed, is a discussion worth having in the theoretical sense only since this patient had made her desire to reject surgery clearly known through her health care advocate and power of attorney guardian.

  • TuckerBenson

    To this layperson, lying around with a broken hip sounds terribly painful. I can see why family members could be easily convinced that a pin would be necessary.

    • Suzi Q 38

      She wasn’t in pain, though, and the surgery itself could cause more harm overall than good.

      • http://www.facebook.com/peggy.bannerman Peggy Bannerman

        The problem with broken hips is that as long as the patient doesn’t move, there is no pain. The pain starts when the patient moves. It’s not realistic to expect a patient to not move for the several months it will take for them to die of pneumonia.

        • Suzi Q 38

          It depends. She could die of pneumonia after the stress of the surgery. Maybe die of a wound infection or nosocomial infection. Maybe her heart was weakened by the surgery, and since she was “smiling and serving tea,” the present array of oral pain meds were working just fine.

          Let’s just say that you are right, which is not what I really think, but O.K. The NP and the surgeon should have asked the attending doctor first, or told him/her (gosh, I must be PC at all times) that they were reporting it because they think she needs the surgery.
          What is this sneaking behind the back of the attending supposed to do? Is that attending going to refer more patients to this surgeon and NP, or is he/she going to call someone else to do his/her patient’s surgeries?

          What they did was not right and should be reprimanded or suspended for a time.

          Reality is that the admin will not do anything.

  • Suzi Q 38

    Even if the surgeon thought that the patient would be better off with the surgery, he should have called the attending doctor for approval.

    I would have stopped the whole thing, and the “re-payment” to the anesthesiologist and surgeon would be that surgeon A that cleared the surgery by phone could pay for surgeon B in the operating room and the anesthesiologist. I would be in the admins office to explain why.

    The problem was that the orthopedic nurse maybe gets a bonus at the end of each year for each patient he/she identifies and refers to the surgeons.
    Maybe he/she is congratulated for each surgery referred.

  • http://www.facebook.com/profile.php?id=1014499897 Nancy Allen

    As the only adult child responsible for my 90+ year old, demented father’s care and decision making, I felt abused by the doctors in our local hospital – by the one in ER who made me feel terribly wrong for wanting only hospice care and who then convinced me to pursue treatment and by the one at discharge who made me feel that I was terribly wrong for misusing the health system by having consented to my father’s treatment.

    • http://www.facebook.com/lori.c.lucas Lori C Lucas

      so sorry to hear this! does your hospital have a palliative care team?

  • Don By

    Lost my father. 97 yrs of age, he asked us they are going to take a 97 year old man and put a pin in the hip? WHY??
    That said it all but it was done. He died of pneumonia, in a nursing, a few months later.
    Seems like the almighty dollar means more than a lot of thing. doesn’t it?

  • EmilyAnon

    Fiction or not, I hope we get an ending to the story. I was riveted.

  • Docbart

    Interesting post. I’m not sure if pinning the hip was right or wrong, although the way it was done is unprofessional. I wonder if the surgeons would have been so eager had they been on straight salary. Is that crass? Sorry.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      How can you tell if they were on salary or not? Sounds to me like this was some sort of hospital standard operating procedure based on the NP’s comments…

      • Docbart

        Obviously, can’t know for sure, based on the post. I doubt they would have this way of doing things without pecuniary motives.

  • karen3

    I am with Steve. It was assault; it was Medicare fraud and the surgeon should have been reported to the police, the state board and medicare. I don’t think your road was the high road, it was the chicken road.

    that surgeon is a sicko and he should be going to jail. Doctors need to take some responsibility to police their own.

  • http://twitter.com/Jrhendrix1034 John R. Hendrix

    I see a failure of communication on the part of Dr. Schumann to discuss
    the plan with his consultants and with the patient’s family. I am an ICU hospitalist at one of the hospitals that Dr. Schumann’s residency program serves and in my head, I yell “let your loved one die” more times than I care to count. I, along with a few other hospitalists, have been working with the orthopedists to establish a geriatric hip fracture program to standardize the care given at our hospital (unfortunately our EHR implementation has put our standardized order set and education of the protocol on hold). I agree communication was done poorly by the orthopedists involved, but why didn’t Dr. Schumann contact his own consultants to discuss the case and communicate the wishes of the family? It appears that Dr. Schumann felt the best option was doing pain control and sending her to hospice but how can the family make an informed decision when not all options were presented. Obviously, the orthopedists explained options that sounded reasonable to the family. Did the orthopedist see money? Maybe. Was it the wrong thing to do? I don’t believe so.

    For the last two years, I have also served as a hospice and palliative care physician for our health system and I agree with the choice the family and orthopedist took. I would have advocated pinning the leg as well as spinal anesthesia to reduce the risk of general anesthesia and once it was over, enroll her into hospice. Stabilizing the hip would reduce the pain which seems to be the most humane option. Yes, the patient is going to die, likely soon. Yes, the patient will never walk again. Yes, this is going to cost money, maybe even wasted. However, turning and toileting are going to be painful. It is likely this demented lady who can’t remember she fractured her hip is going to try and move around in bed, also quite painful. Pinning the hip may reduce the amount of opioids required to control the pain which may allow more wakeful and interactive time with the family in her last days, maybe even serving tea to them.

    • Suzi Q 38

      ” I agree communication was done poorly by the orthopedists involved, but why didn’t Dr. Schumann contact his own consultants to discuss the case and communicate the wishes of the family? It appears that Dr. Schumann felt the best option was doing pain control and sending her to hospice but how can the family make an informed decision when not all options were presented. ”
      1. Yes the orthopedists were wrong to to what they did, how they did it, without the knowledge of the doctor in charge. Sneaky.
      2. Pain control at her age costs very little. How much pain is involved with the surgery itself? Healing? Risk of infection and anesthesia?
      If the patient at 94 years old went to hospice with mega meds and did not miss a “pinning” so what?
      3. I come from a big family. I am the assigned POA for our 88 year old mother. There are a few times when the family had various different ideas on how to medically treat our mother. I am not sure why my mother chose me to be the “last say.” If this had happened, I would have been so mad that I would have complained at the patient advocacy department. My siblings have a say, and I will listen, but I make the decisions. Why? Someone has to do it.
      I would have been ticked off if a surgeon called my other siblings to get approval without me, the one in charge. This was not a life saving procedure. Anything but. $$$ signs all the way.
      Dr. Schumann needs to also contact the POA (son of the patient) and get him to complain to the patient advocacy.
      Punishment should involve money sanctions equal to what they would have been paid for the procedure, paid to charity.
      4. Are all options presented in all cases?
      For example, if the orthopedic doctor wants to do hip replacements with other patients, does Dr. Schumann and others get to tell all of your patients how risky the surgery is going to be? Does he get to present all facts so that they can make a full informed decision??
      Do the get to view the patient’s chart and contact all family members for each case?

      I think not.

      • http://www.facebook.com/sraut79 Sourendra Raut

        Your reasoning is somewhat flawed. While it is quite unfortunate that such a miscommunication occurred, this is an example of a system failure, not a failure of one physician group. Both the orthopaedic surgeon and internists should share the blame.

        A surgery to stabilize the hip has limited pain when compared to the extreme pain of mobilizing a patient with a hip fracture.I would be wary of having an internal medicine physician discuss the risks associated with surgery without him having full knowledge of what such a procedure entails.

        Cases such as these are not as clear as they appear; having done my orthopedic training in Canada, I can advocate for the perspective of the orthopedist in this example. Regardless of the cost of the procedure, when patients families are presented with an option of a 30 minute procedure with limited blood loss and pain that will cause immediate pain relief (as is the case with a hip pinning) versus constant pain with motion, high risk of pneumonia, bed sores, soiling oneself, etc. many families will wish for the surgery.

        • Suzi Q 38

          Yes, my reasoning may be flawed as I am not a doctor.

          This is more than poor communication. The NP called in her ortho and called the family members without consulting the presiding doctor in charge. Also, they called different family members that did NOT have the official POA. The ortho and crew have not only overstepped, but maybe have violated legal protocol as far as POA. Foe example, my FIL’s wife did not have the POA for FIL, his son did. He would not have been happy if his stepmother made health decisions for his father just because the ortho felt like calling someone else on the list (because they didn’t get the right answer the first time around).
          This is very calculated and sneaky. It may be violating some ethics or patient care regulations. How would you like it if someone took your patient, did more surgery or treatment(s) on YOUR patient, knowing all the while that the presiding doctor did not share your view.
          If the ortho felt that strongly about going ahead with the procedure, at least arrange for a quick meeting with admin and inform the doctor that a meeting was going to take place. That is the least the ortho could have done.
          This way, each party could have plead their case, and an independent social worker could arrange for another meeting with the POA (son) and any other family members that were concerned.
          Maybe then the other family members could persuade the son with the POA to change his mind.
          At any rate, I would have complained vehemently, demanded an apology, and called the insurance company to say that I never authorized this surgery.

  • Barry Nuechterlein

    Wow. What a miserable situation. There’s a lot of blame to go around, here, and it sounds like a situation where structure and communication were lacking.

    While it can be debated whether medical or surgical management would be more appropriate for this patient, the manner in which this unfolded is an ethical and legal nightmare. Unless the surgeon contacted the POA, and the POA changed his mind, this is a case of performing a procedure against the wishes of the legally responsible individual.

    Of course, if the surgeon had a discussion with the POA and that individual changed his mind, the surgeon should have informed his colleague, but that is a much less serious lapse. Discourtesy and rudeness stinks, but it’s not a crime. Exactly how this unfolded, and who ultimately gave consent, is left a little ambiguous.

    It also sounds like there’s a good chance the anesthesiologist missed the boat, here. It is chastening for me as an anesthesiologist to hear this story, and it reinforces the point that every effort should be made to review the record and touch base with the POA (I am presuming that Dr. Schumann documented his discussions with the POA/family and the NP legibly and completely).

    This kind of situation is why I try to touch base with the legally-appropriate decision-maker before starting a case in a confused patient, even if I’m busy and it’s the middle of the night. This is doubly important if there is disagreement between family members or ambiguity/contradiction in the record. I am also an ethically and legally responsible individual, and have a responsibility to obtain consent for my own procedure (an anesthetic) from the POA in a non-emergent situation.

    Without knowing more specifics about the communication between the surgeons, the anesthesiologist, and the POA, it’s hard to say whether this is a crime or not. One thing is for sure; a quick phone call from the surgeon to his Medicine colleague to inform him of the change would have prevented a lot of trouble.

    What a mess…

    • Suzi Q 38

      I agree. I am glad that you chimed in as an anesthesiologist.
      There is a definite violation of legal ethics here regarding the official POA. Many times, siblings do not agree, so a parent (in their best judgement) puts the closest and most responsible adult child in charge as the POA. If they are legally savvy, it is the one that has NOTHING to do with the estate money. Please do not assume it is the wife/husband or an adult child. You could be meeting or speaking with the 2nd or 3rd spouse, or a step child; all of which do not have the official POA.
      Sometimes it is the most knowledgeable, or the calmest son or daughter. Sometimes, the son or daughter is the one with some medical background. Whatever the reason for the parent’s choice, it is the patient’s choice. The POA’s answer, whether you agree with it or not, is the answer, and is legally binding in most states and situations.

      When my mother was ill, all of us rushed to her side. I had the POA.
      My brother tried to put a DNR on her immediately, but I wanted to give her a chance by authorizing a feeding tube when she was rapidly declining and wasn’t eating. Another sister agreed with him, and we argued. I had to show my papers to the nurse and called the attending doctor, who also definitely wanted the tube in. It got put in because I had the legal and ethical power to authorize it. Even though everyone though she was going to die at the time, she ended up getting well, making a remarkable recovery and is still alive today, living at home on her own..4 years later.

      If I was the POA in this case, I would definitely make the administration and ortho surgeon, anesthesiologist and NP aware of my unhappiness and anger at how this all developed.
      I would not pay any co pays. I would laugh at the suggestion. If they turned my bill over to collections, I would sue them in small claims court and probably win. I might also find out if I could get sanctions on behalf of my mother for pain and suffering. All because the surgery should have never gone forward without the POA in the first place.
      I would complain to the insurance company and have them review it.
      If the hospital did nothing to reprimand the medical professionals involved, I might complain to the state medical board and joint commission. THe surgeon, anesthesiologist and NP would have to apologize to me in a formal meeting at the hospital, with my siblings present, to provide clarification of the “facts.” Especially, who called who, when, and what was said. Why wasn’t the POA called for the discussion the second time around? Was it because the surgeon feared his decision or answer? The patient advocacy department could facilitate such a meeting.

      This way, if all goes well with the patient, fine. Everyone’s “hand is slapped” for the future. If not, and my parent declines due to this procedure done against my (thePOA’s) wishes and approval, the parties involved could be in for more problems that they ever envisioned in the first place.
      Yes, the surgeon could say “But, there was a DNR anyway!! why should I be responsible???” Exactly. Good point. There was a DNR. That means, DO nothing, unless otherwise authorized by the POA.

      Next time, if you are going to screw up, show others who is the “boss” and do something stupid like this, just cover your @$$ and get approval from the correct POA.

      • Barry Nuechterlein

        What I can’t figure out was whether it was the POA or somebody else who supposedly gave consent for the surgery to go ahead. People do change their minds, sometimes. The language in the essay is kind of ambiguous.

        This is exactly the kind of situation where good communication is important…it’s kind of hard, even now, to understand just what it is that happened…

        • Suzi Q 38

          “Did you and your siblings consent to this procedure?” I asked them. “Yesterday your brother and sister told me that they wanted no further intervention; they wanted your mother to go to hospice to live out her remaining days in comfort.”

          Yes, it is unclear.
          The POA (son) could have changed his mind and told his two sisters it was O.K.

          I don’t get that from the article.

          If not, and the surgeon went with the two sisters that were there, they could be in for a bit of trouble if the POA did not want this done and was firm about that.

          I would have asked the two sisters if all 4 were in agreement, or maybe tried to call the POA.

          If not, pull her off of the table, as it is not a life saving emergency and no official authorization was given.

          The POA is in charge, especially if it appears that siblings do not agree.

          • Barry Nuechterlein

            True. The POA is in charge. I just can’t figure out what his final decision was. The more I try to parse the language, the less certain I am of how this all transpired.

        • Guest

          True. The POA is in charge. I’m just not sure what his final decision was. The more I look at the essay, the harder it is for me to figure out what happened.

  • http://www.facebook.com/lori.c.lucas Lori C Lucas

    another thing I would like to mention is how the medical system often ‘tortures’ families by asking them things over and over again, as in “are you sure/this is cruel/I wouldn’t handle things like this”…making some of these end of life decisions can be so difficult, and when a family finally comes together and agrees on a plan, it can be beautiful and a relief! When we constantly say “are you sure?”…we put doubt, force them to reconsider…heaven forbid the patient ends up in the ER! families go through the trauma and guilt again and again.