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Friday, September 18th 2009

A Sense of Urgency

A traumatic subdural with a pretty good shift deteriorates on his transfer from some rural area, gets to your hospital as a GCS of 7 and needs to go to the operating room emergently. His next of kin rode on the transport to your hospital. Other family members are en route by car but are some distance out.

You try to consent his next of kin using phrases like ‘emergency,’ ‘right now,’ ‘life and death’. The response is a lot of waffling, a request to wait until the rest of the family gets to the hospital, and calls to those same family members seeking advice.

I seem to have run into the above, or the equivalent, several times over my still young intern year. Not every night or every week, but a few times. Too many times.

I understand such situations are incredibly stressful for those presented with a decision for an emergent procedure (or not) for a loved one. I understand a lot of information is presented to them in a short period and they’re asked to digest it under stress and make one of the most important decisions of their lives.

I’m not sure it excuses trying to skirt the responsibility.

The most frustrating instances involve those legally responsible asking you as the provider to seek the opinion of other family members and to have them decide.

“Oh, I just don’t know! Can you call his sister and have her decide?”
“I’m happy to talk to her and anyone else in the family, but this is something I really need consent from you for.”

Admittedly it could be me. I don’t think so however. I think I present the situation generally with the proper sense of urgency and yet lay out the decision to be made and the options and the consequences of each option in a pretty down to earth and understandable way. The few times I’ve run into this, others – my residents, fellows, faculty – who have come along to talk to the family after me have had the same problem.

True, maybe as the first to attempt consent I’ve spoiled the whole pot for all who follow. More likely the commitment and responsibility owed to a loved one breaks down under the spotlight of the situation for some.

Decisions under time pressure, with limited information, with a loved one at stake are incredibly difficult and I try to check my frustration. However, a sense of responsibility is just sometimes lacking from those asked to choose to either put the pen to the consent form or to refuse to put the pen to the consent form.