Tales From Geriatric Practice

The Patient Who Changed Her Mind

Mark E. Williams, MD

Disclosures

March 09, 2021

During my geriatric fellowship, I cared for a patient in her early 80s who'd had a minor stroke. She was a retired teacher, had never married, and had no living family members. Because there was no one at home to help care for her after her stroke, she was admitted to the nursing home under my care.

A thoughtful and deliberate patient

I performed a thorough exam and we talked about her life — and her current situation.

"Doctor," she said, "I've lived a long and full life, and I've done a lot of thinking about what type of care I would like at the end of my life. I don't want to be sent to the hospital. I don't want antibiotics, intravenous lines, or a feeding tube, and I certainly don't want to be placed in an intensive care unit. I want you to make sure that I'm comfortable. Please let me die a peaceful and natural death."

Afterward I reconfirmed her wishes and wrote a detailed note in her medical record to that effect.

Honoring my patient's wishes

About 3 months later, my patient developed urosepsis. She was lethargic and very sweaty. Her pulse was barely detectable. She appeared comfortable. My medical care for her was based on our previous discussion. I made sure she was offered water, but I didn't order any antibiotics or bloodwork. Her vital signs were low, and she had no urine output for nearly 3 days.

A turn for the better

On the fourth day of her illness — to my great surprise — my patient began to improve. She took some nutrition and eventually made a full recovery to her baseline level of function.

A change in circumstances, a change of heart

A couple of weeks after her illness, my patient and I had an interesting conversation.

"Dr Williams," she said, "I want to thank you for not honoring my wishes and for saving my life. I recalled the conversation that we'd had several months ago when I told you what I thought I wanted. But when I was looking death in the face, I changed my mind. And I want to thank you, from the bottom of my heart, for not honoring my wishes and for saving my life. I am deeply grateful for your wisdom and for pulling me through."

Naturally I was stunned, especially because she had been so specific about what she wanted. Rather than "correcting" my patient's impression of how her care had unfolded, I simply told her that I acted out of compassion for her, without providing any details.

I left her room and went down to the nursing home library. A particular research study caught my attention. It involved a group of informed pregnant women who all wanted natural childbirth. The investigators carefully documented each woman's wishes and then compared this "advance directive" with their obstetrical records.

The findings? None of the women had natural childbirth. They all wanted some form of analgesia when they went into hard labor. The women were young, intelligent, and knew exactly what they thought they wanted. But when their circumstances changed, they changed their minds.

Upon reflection...

As a physician, I must honor my patients' expressed wishes about their care. But wishes change, as this encounter made clear. Even though we often (although not always) have patients' advance directives to guide our care, I still don't sleep any easier. Anticipated circumstances can change, and thoughtful people can change their minds.

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