Case and Commentary
Jan 2005
Case
Even after he was informed of his new diagnosis, Mr. Douglas was steadfast in his refusal of bypass surgery. A few weeks later, Dr. Kim was only half surprised to get a phone call from Mrs. Douglas informing him she was taking her husband to the ER. Dr. Kim arrived as Mrs. Douglas was describing what happened to the ER physician.
"I found Allan lying on the kitchen floor. He said his chest hurt and the pain wasn't going away like it usually did. I decided to take him to the hospital. I grabbed the aspirin and the nitroglycerine you gave him. He was wheezing and having trouble breathing. He actually threw up in the car. Then he swallowed the nitroglycerin and I don't think he threw up again. He passed out on the way here and only woke up when they helped him from the car."
Dr. Kim checked Mr. Douglas's pulse, which was weak, and noticed his sweat-soaked clothes. His systolic pressure was 65. Dr. Kim paged Dr. Carlson.
When Dr. Carlson arrived he received a synopsis of what had happened and then asked Mrs. Douglas a few questions.
He asked for BP measurements in both arms to check for aortic aneurysm. Ruling that out, he ordered tests on cardiac enzymes, CBC, and electrolytes and a coagulation profile. He also ordered an ECG, to get a current picture of the location and severity of the blockages.
"He's in cardiogenic shock," Dr. Carlson soon announced. "Get a cardiac surgeon down here."
Dr. Imenez arrived and was informed of the situation. After examining the previous angiogram and ECG, he and Dr. Carlson explained to Mrs. Douglas that, because of the location of the blockages and the number of them, Mr. Douglas's best chance for long-term survival was bypass surgery.
Mrs. Douglas gave Dr. Kim a concerned look. "I know he told you that he didn't want bypass surgery, and I guess if there's another option I want to pursue it."
Dr. Kim took a moment to respond, "Mrs. Douglas, I tried to convince Allan he needed bypass surgery, but he was really concerned about some business deal. He's not going to be able to do any business deals if he doesn't have this surgery."
Dr. Carlson added, "If any other treatment, like coronary angioplasty, had a reasonable chance at success, we might try it, but, given the location and severity of the blockages, his long-term survival is substantially diminished with any treatment other than surgery."
"If he didn't want the surgery, I don't think you should do it," Mrs. Douglas responded.
What should Drs Kim, Carlson, and Imenez do? (select an option)
A. Get a court-appointed guardian other than Mrs. Douglas.
B. Continue recommending bypass surgery to Mrs. Douglas.
C. Prep Mr. Douglas for bypass surgery.
D. Treat Mr. Douglas without surgery (ie, catheterization or pharmacological treatment).
