The swastika-donning patient who refused his lactulose

As a third-year medical student rotating on the internal medicine service at the VA Hospital, I took care of an elderly patient who was suffering from decompensated alcoholic cirrhosis.  His condition was complicated by hepatorenal syndrome, multiple electrolyte imbalances, and hepatic encephalopathy.

It was most complicated however by various ethical challenges and by the social and familial factors surrounding this patient’s course of treatment during his one-month stay on our service — and further by his dispositional affect that made me regularly question whether we were offering this patient the care which he truly would have desired, if he were able to more clearly communicate his wishes, or rather offering excessive life-prolonging therapies amidst a virtually futile prognosis.

This patient was memorable because he was the sickest on our floor and because of how involved his adult children were in his care.  He was also particularly memorable, because in a hospital where veterans have a reputation for being friendly and grateful patients, this patient donned a swastika tattoo on his wrist amongst various other illustrations scattered around his body, reflecting a time in this patient’s life when he must have been vocal about his general hate toward others.

On a day-by-day basis, he would transition back and forth between an encephalopathic state in which he was completely somnolent and lucid moments in he would state, “Get the hell out of my room!  I ain’t shoving any damn lactulose down by throat!”

While this may have seemed like enough to establish that the patient’s wishes were to forego further aggressive therapies, the situation was made more difficult by his daughter’s emphasis that, “This is just how he is.  He has been like this all my life, and he definitely wants us to do everything we can to keep him alive.”

In moments like this, all I could do to keep my sanity was to assume that she and her brother knew her father better than I did and that each of my team’s actions was carried out with a commitment to beneficence and the best interests of the patient.  Otherwise, I could not help but feel like I might be involved in doing more harm than good as we took such actions as placing a Dobhoff tube for continuous feeds, performing regular diagnostic and therapeutic taps, and administering multiple daily lactulose enemas given the patient’s refusal to take anything by mouth.

To me, the medical student who spent a substantial amount of time with the patient and had the opportunity to see moments of clarity in his language and behavior, it seemed like the patient was quite clearly indicating that he had been through enough and that we should leave him alone.  In spite of these moments, the patient was deemed incapacitated, and his daughter maintained durable power of attorney.  Over the course of the patient’s admission, I came to know his children quite well, and I am confident that their hearts were in the right place; it crossed my mind that maybe they had never had a positive relationship with their father, and this was an opportunity for them to gain some closure, or maybe they viewed any option of halting further treatment and allowing their father to die as the same as choosing to give up on a loved one.  Or perhaps they simply weren’t sufficiently attuned to medical science and end-of-life care to know when it was appropriate to move toward more palliative measures.

I recall one time when the patient’s daughter asked me, “So is the next step for the kidney doctors to basically create the perfect ‘potion’ to get my dad’s electrolytes and numbers back in balance?”

Our team did engage in meetings with the family to reiterate matters of prognosis and to ask them their views on the manner and circumstances under which they would most prefer their loved one to eventually die.  Ultimately, however, the patient’s family continued to pursue a mostly unrealistic outcome, and the patient’s condition stabilized to the point where he met criteria for discharge.  I will always wonder if the patient left the hospital on that discharge day with a sense that the wrong issues had been addressed during this stay.

Moreover, as a future physician, I will continue to question how we may have made this situation more understandable and as peaceful an experience as possible for a family who was just trying to do what they probably thought was right.

Mark Edelstein is a medical student. 

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