Importance of Advance Directive

 Thursday was like any other work day. I was trying to get through the day one patient at a time starting 7:00 am. By 3:00 pm I had the last 2 patients to see before I could go home.

I went in to the patient room to see a 54 year old woman who is intellectually disabled and accompanied always by her companion/ caregiver. The man is in his late 80s and has been my patient for nearly 2 decades. We had always shared a warm relationship. He would always tell me “ Doc, travel as much as you can while you are able to. When you get to my age even if you have money, the knees,back and legs may not cooperate.” 

 A few years back he brought his companion to establish care with me after she switched insurance. This woman was here this week for her papsmear. He waited in the room across from hers to allow me privacy to complete the procedure. 

My assistant had prepared her for the pelvic exam. She seemed ready but anxious, which is not at all unusual for most women coming for this procedure. To put them at ease I often joke that they are not the first one to feel that way, I have never met a woman who likes to get a pap smear. Likewise I tried to help this lady relax in every possible way before I undertook the actual pelvic exam. But she was too uptight no matter what. I tried, paused when she complained of pain, made her relax and tried again. She just wouldn’t cooperate to allow the speculum beyond a few centimeters.After 3 earnest attempts I decided to quit and told her to schedule the test with a gynecologist. She was happy to be off the hook.

She was due for some vaccine updates that day. After I left the room my assistant was going to complete these shots before discharging her. I gave the necessary orders to the assistant and went back to my office. Just as I was preparing to go see the last patient of the day I got a phone call from my daughter who was walking to her shift at the emergency room in San Francisco General Hospital. I had barely said hello to her when the assistant came to my room and said impatiently “ doctor your patient is having a seizure “. 

I abruptly cut the phone call telling my daughter “ I need to go “ and rushed to the patient room. The lady was still in her chair, shaking her arms and legs vigorously and her eyes were rolled up. By then, by protocol,the nurses and other rescue team was summoned to the room. We laid the patient on the floor for her safety, attending to her emergency. She was incoherent and unable to follow verbal orders or to swallow her anti seizure medications. I gave orders for the medication to be administered through IV mode. The nurses couldn’t find a vein to start a line. Next best option was to give the medication through the rectum. Despite that she wouldn’t stop convulsing. By that time one nurse had managed to find a vein and we could push in the medication through that. Even after this the shaking wouldn’t stop and she was not coherent.

All this time her companion sat watching the drama from the room across and repeatedly pleading for us to not send her to the hospital. He said long time back it was determined that she did not have “ real” seizures and the doctors at UCLA had told him not to take her to the ER or “ they would kill her there” !! 

In between managing the patient I was reassuring him to trust me that I would do whatever was needed in her best interest. Without a signed document that gave him the authority to decide on her treatment I was bound legally and morally to use my medical judgment to direct her care even if it was not aligned to his wishes. 

Much to his protests I had to summon the emergency medical team ( EMT/ ambulance) to take her to the nearest ED when she failed to show signs of recovery after the medications we could give her in the clinic. Even after they got her on the gurney and wheeled her out of the clinic I was trying to make him understand my reasoning and to reassure him that all will be well. 

An hour or more was spent dealing with the unexpected turn of events. In the interim the patient after her ( last patient of the day)decided she would reschedule her appointment to allow us to attend to the emergency. 

I was finally done for the day at work. But the mind was disturbed. The man’s desperate pleas were haunting me. The moral dilemma of disregarding his requests, despite the fact that he knew her best after years of caregiving, and acting upon what my honest medical judgment told me was best for her at that hour, would not allow me to drive home with the usual feeling of relief or a job well done.

It quite naturally came to my lips that night when I was talking to my husband. And to my daughter. 

The next day( Friday) at work I looked up the records. The patient was still at the hospital. All I could do was keep praying that there would be a good outcome.

Saturday went by. I had her thought in the back of my mind. Today Sunday was also packed with a lot of commitments. Yet I couldn’t ignore the thought of her. After an early morning weekly zoom chat with my spiritual group, I had to leave the home to make it on time to a friend’s home for breakfast. My feet wouldn’t leave without calling the patient.

 I opened the work computer and logged in, found her phone number and placed the call. 

Can’t express my emotions as I heard her voice from the other end. How are you? I asked . I’m fine, she said. “They found I had an infection in my urine that caused me the seizure and sent me home with antibiotics”.

I then asked to speak to her companion. Are you happy Sir that she is well and home ? He was unmistakably happy and relieved. What more did I want ? After this reassuring call I was a free bird to carry on with the rest of the day’s commitments.

The story highlights a very important issue that is often faced in my profession. Importance of having legal documents that give clear authority to family members to make the decisions when a patient is incapable of communicating his/her preferences. Despite us urging them to stay prepared with these documents which are commonly referred to as Advance Directives, most patients and families are unprepared when the moment arises, such as one I faced on Thursday. That leaves the physician in the difficult situation to sometimes act contrary to what the family wants. It is a lot of pressure on all parties involved. 

Me and my husband signed our advance directive documents over 10 years back even though that was not the age one usually expects something dire to happen. I hope more people will understand why it is important to give a thought to this issue and complete the paperwork and have it with them in their car/ purse and with their relatives to produce when an emergency arises. It would help them and it would help their medical providers immensely. 

Saree today is a georgette with Kashmiri embroidery I had picked up at an exhibition in Pune over 10 years back. Today pulled it out after an offline conversation with a dear saree sakhi who implored me to dress in my saree that I told her was similar to hers after she shared her picture.

Thank you Ranjana Ramakrishnan ! I am back with my post because of you 🙏🏼💕