Consent

My hands were in someone’s abdomen when the page came through. I was changing the dressings for a patient who had been in the hospital for months with half-loaf-of-bread-sized wounds on his abdominal wall. As I laid down a black sponge, that my patient aptly described as air-conditioner insulation, into one wound and smoothed paper-sized sheets of tape over top, the pager clipped to my waistband started to beep and buzz. I managed to silence it with my elbow, a decent hospital party trick. Five minutes later it went off again and this time, I paused, pulled off my gloves and looked: “Concern for dead bowel, please call STAT.”

As a second-year resident, I was covering a fourth-year gig as the Trauma and Acute Care Surgery consultant. I got paged about every patient in the hospital who developed any surgical- seeming problem and followed a list of 20 or so patients who resided under the care of other teams, but needed surgical guidance. I also operated throughout the day, and did dressing changes and evaluated new patients in the 15 minutes between cases. I was insanely busy, but “dead bowel” is the kind of phrase that stops you in your tracks, and forces you to turn course.

I quickly wrapped up my work, leaving a med student to apply the finishing touches, and logged onto the closest computer to check out the patient from the page. First, his vitals: high blood pressure (a good sign), normal heart rate (reassuring), a fever (more concerning). Then his labs: his white blood cell count was through the roof (a horrible sign) and his lactate, a chemical produced by dying organs, was normal (either a good sign, or meant that the bowel was past the point of dying and was already dead). Lastly, I opened up his CT scan and saw black specks of air dotting his liver’s blood supply and dancing along the edges of the bowel wall (the scariest sign). I crossed the hospital from one building to the next and dashed up the stairs to see the patient and collect my final data point: his exam. He was confused, unable to answer basic questions, with ominous purple blotches on his skin. He screamed out when I lightly touched his belly. This guy needed to go to the operating room emergently.

I called the attending surgeon. “I have an emergent operative consult for bowel ischemia,” I said, priming him for the story to follow. “Just come down to the OR,” he told me.

In the operating room, I pulled up the scan on a big television-sized computer screen and scrolled through the images slicing the body from the pelvis up to the top of his lungs, showcasing the black specks of air to my attending who was scrubbed into another case. “Ok, consent the family and book the OR.” He said.

I called the patient’s wife and broke the bad news in a calm, but urgent tone. It’s tricky going from an immediate introduction, “Hi I’m Dr. Blank, with the Surgery Team at Blank Hospital” to the Bad News: “I got called to assess your husband for abdominal pain, and while he’s okay at this moment, I’m worried his bowel is dying and he needs emergency surgery.” Next, I explained what the surgery would entail: removing the dead bowel, washing out the abdomen, and likely leaving her husband’s belly wide open with only a surgical sponge separating his organs from the outside world. Then, in a couple days, once he stabilized, we would return to the OR, and bring the end of the cut bowel up through the skin, creating an outlet for stool called an ostomy. We’d close the big incision, but for the rest of his life, the patient would pass stool through a hole in his skin, into a bag secured over top. A small piece of his bowel would protrude from his skin, a few inches over from his belly button.

“He never wanted that,” the wife said. “I know that for a fact.”

“I understand. If this surgery isn’t within his goals of care, if this isn’t something you think he’d want, that’s your decision to make. We want to prioritize his wishes.”

On the other end of the line, I heard panic in her short-of-breath responses, “I don’t know what he would want. I’m not sure. I just can’t think right now. Can I ask my sons? I want them to decide.”

Over the next 30 minutes, I played phone tag with the wife and her sons, each of whom was in the midst of something. On hold, waiting for the eldest son to come back on, I watched the OR nurses begin setting up for surgery, draping the tables with blue sterile sheets, opening up metal containers of instruments. At the same time, I furiously typed my note on the consult, concluding with, “Plan to proceed to the OR emergently.” This patient would die without surgery. We needed to have him downstairs, on the operating table, within the hour. The team sprang into action, getting the room ready, before I even had consent from the family.

In an ideal world, consent would be obtained before instruments are opened and before personnel — anesthesiologists, nurses, techs — are pulled into the case. But in reality, we don’t waste any time in these settings. If it takes the family 30 minutes to decide to go for surgery before we begin setup, that’s a 30 minute delay in getting the patient to the OR. So instead, we juggle tasks simultaneously in emergencies. It’s easier to stop the setup process if the family decides to hold off, than to risk this man getting sicker and potentially dying due to delays in getting the room ready. Plus, families typically agree to life-saving surgery, especially in younger patients like this man.

The son came back on the phone. “Can I call you back in 15 minutes?” he asked.

I paused. I wanted to give him the space he needed, but also knew we didn’t have much time. I needed to be firmer.

“Your dad will get very, very sick if we don’t take him to the operating room right away. He could die. If you think that he wouldn’t want an ostomy, that it would be against his goals, we of course, won’t proceed. But I do want to be clear that he has a life-threatening problem that, if we want to fix, needs to happen as soon as possible.”

“He never wanted an ostomy,” he said. “He told us that explicitly. But I have kids, I want them to know their grandfather. Okay…you have my consent for the surgery.”

After having a colleague confirm consent with the son, we signed the form, and went up to wheel the patient down. Within twenty minutes, he was sedated, intubated, OR lights flooding his translucent skin studded with the ominous cob-web of purple streaks known as “mottling”. The senior resident and I opened his abdomen with an electric knife. Our attending surgeon, coaching from the sidelines, reminded us to stay midline, entering the abdomen through the fascia that adjoins abdominal muscles, instead of cutting through the muscle itself. The moment we broke through the peritoneum, the thin lining that separates organs from muscles, a horrible smell swept up beneath our masks. Sometimes you can sense sickness well before you see it. It didn’t take long after that to find the blue-green segment of bowel that was dead. We cut and stapled it along each end where it turned back to a healthy rosy color, removing the dead section and leaving two separate ends sealed like Hot Pockets. We packed the abdomen with a surgical sponge, similar to the “air-conditioner insulation” but made of a different, blue material. We placed sheets of tape over top, creating a protective barrier between this man’s abdomen and the elements. I thought back to placing tape over an abdominal wound just a few hours earlier. It felt like a full day separated these two dressing applications; time both dilates and shrinks in crises.

After we brought the patient to the ICU and the dust settled, the son’s words played in my head over and over. “He never wanted an ostomy.” His wife had expressed the same sentiment. Told me her husband was a proud, stoic man. Said he’d be humiliated by stooling into a bag for the rest of his life. “But I have kids,” the son said. Unable to ask our patient what he would have wanted, we were left to rely on the family’s wishes — wishes that ideally would be consistent with what the patient had expressed previously, but that isn’t always the case.

Sometimes family members are left to make decisions with insufficient information from their loved ones, or they’re faced with the gray, murky reality of health care, and find that the black-and-white notions their loved one had once shared no longer hold up. Beyond the confusion, the truth is we can’t necessarily predict what we will want in the midst of acute illness. Does the idea of an ostomy seem as horrifying when facing imminent death as it does when sitting in your living room, chatting with your family? For me, at least, it wouldn’t seem like the worst option compared to painful demise.

But I can’t project my desires onto others. We have to trust people and their loved ones to make these life-and-death decisions, to ensure that our care aligns with their wants. Out of context, I can feel good about helping to save this man’s life, but I remain uneasy thinking that, maybe, he wouldn’t have wanted his life saved under these circumstances. Maybe, if he had been able to make the choice, we would have stopped the OR setup, and worked to make him as comfortable as possible until death. That would’ve been his right.

I also let my mind wander in the opposite direction: Maybe after he was extubated and came to, and realized he had an ostomy, maybe he’d hold onto his youngest grandchild and shed a few tears, grateful to still be alive. Maybe he would talk to his son and thank him for making the right decision on his behalf.

But unfortunately, I didn’t have time to follow up and figure out where he stood. I was already onto the next page, mixed up in the next crisis.