The Case

A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease, his code status was Do Not Resuscitate/Do Not Intubate (DNR/DNI), though he was still receiving active care. The patient was suffering from multiple concurrent infections requiring intravenous antibiotics.

The patient in the room next to him was also receiving antibiotics. Inadvertently, the antibiotics were switched at the nursing station, resulting in the administration of Nafcillin (a penicillin-like antibiotic) to the AIDS patient, who in the past had a known anaphylactic-shock reaction to penicillins. The difficulty was, if the AIDS patient developed anaphylaxis to the Nafcillin, there was a good chance he would suffer a cardiopulmonary arrest, given the advanced state of his illness. If this were to occur, he would likely die if heroic measures were not taken.

The nurse taking care of both patients realized the error after she went to give the other patient his antibiotics and saw that the printed label did not match the patient′s name. Unfortunately, the wrong medication had already been given to the AIDS patient. After noticing the error, the nurse called the covering physician. The physician spoke to the patient, advised him that he might possibly suffer anaphylaxis to the errant medication, and asked him if he wanted to maintain his code status as DNR/DNI.

The patient was treated prophylactically for the possibility of allergic/anaphylactic reaction. For the next several hours, his nursing care became more intensive with more frequent vital sign checks. Luckily, he did not suffer any adverse outcome from the medication. By the next morning, it was clear that there were no sequelae.

The Commentary

Making an error that injures a patient causes many clinicians the greatest distress of their professional careers. Clinicians may feel that they have failed and may experience shock, grief, shame, and guilt. They may also fear the consequences that the error may have for them, including loss of status, disciplinary action, or malpractice litigation.(1) Typical coping mechanisms include hypervigilance, characterized by excessive attention in what may be a vain attempt to undo, atone for, or make up for the harm done. In one case, a provider who gave his patient an overdose of a medication described his response as ′36 hours of rapt attention.′(2)

In some cases, our reactions to our errors may alter usual clinical decision-making. The cardiac transplant patient at Duke who received a heart-lung transplant with an incompatible blood type is illustrative. The patient, clearly dying as her initial mismatched transplant failed, ultimately received a second transplant even though the prospects of success were remote. This action could be interpreted as the clinicians′ attempt to right their wrong, or to give a second chance to a patient who had been profoundly unlucky. However, this decision may have deprived another patient with a greater chance of benefiting from the organ. One could argue that the clinical decision was flawed because the clinicians were trying so hard to ′make up′ for their error.

We believe the second transplant at Duke may represent a more widespread phenomenon than has been previously appreciated, in which patients receive more aggressive care after an iatrogenic injury than they would have otherwise received. There are no data on the incidence of this phenomenon. However, research suggests that physicians may feel a greater obligation to treat when an illness results from the physician′s error.(3) They may also fear that they will be more likely to be sued if they do not take all possible measures. Unfortunately, more is not always better, and not always consistent with patients′ wishes.

If the patient in this case had arrested, the decision to attempt resuscitation should still have been based on the patient′s wishes, rather than on the clinician′s remorse. An ethical analysis suggests that the admonition to ′do no harm′ does not override an autonomous patient′s refusal of treatment.(4) Nor should the patient be subjected to an undesired resuscitation as part of a defensive strategy to thwart litigation. Physicians may believe that DNR orders do not apply in the case of iatrogenic cardiac arrests. In one survey, physicians responded that they would be more likely to override a DNR order when an arrest was caused by a complication of treatment.(3)

When a patient′s detailed wishes are known, the decision is clear. A thornier issue arises when it is not known what a patient would want in a specific situation, including iatrogenesis. For example, what if this patient had suffered an immediate anaphylactic reaction, and his wishes regarding an iatrogenic arrest were not known (as they usually will not be)? In the absence of such knowledge, the clinician may feel obligated to treat immediate life threats and then obtain additional information from the patient or a surrogate.

Physicians may believe that patients are not thinking about the possibility of an iatrogenic cardiac arrest when they consider resuscitation preference. This problem could be alleviated by eliciting more detailed preferences at the time of DNR discussions. Patients should understand that DNR orders generally apply to arrests in which the probability of successful resuscitation may be either high or low, depending on the clinical circumstances. They should also understand that arrests can be expected or unexpected, and may even be caused by medical care. Incidents that put patients at risk are frighteningly common, particularly for severely ill patients. Research suggests that virtually all patients in intensive care units experience potentially life-threatening errors in their care.(5,6) Patients can be asked directly how they would like their care handled in each of these situations, some of which could be acute and reversible. For seriously ill patients, the circumstances of ′double effect′ could also be mentioned: ′What if I gave you a usual dose of pain medication, and it made you stop breathing—would you still not want us to try to resuscitate you?′ The distinction should be drawn that a DNR order is not tantamount to abandonment—something that many patients fear. It should be emphasized that the team will continue to provide care and caring under all circumstances.

One helpful way to structure these discussions involves four steps: discuss prognosis with the patient or family, evaluate the extent to which patients or families want to be involved in decision making, establish goals based on the prognosis, and implement therapies that help achieve the goal and eliminate those that do not. Immediate life threats, if treated, may not affect prognosis. This process is iterative and decisions need to be revised frequently. For example, if the patient desires, physicians may acutely treat an anaphylactic reaction from a medication error. However, if the event altered the patient′s prognosis (eg, if after several days the patient was still on mechanical ventilation and receiving vasopressor therapy), the goals should be reevaluated.

We are incorporating these four steps (establish prognosis, establish degree of involvement in decision-making, set goals, revise therapies to achieve the goals) in a checklist that is part of our ′ Daily Goals Form. ′ (7) We are pilot testing it on patients in the ICU longer than 5 days, since the majority of these patients will not be discharged home. Checklists such as these can help ensure that key steps in the process are reliably accomplished. Nevertheless, these discussions should ideally occur with the patient ′ s primary care physician—who has a better understanding of the patient′s values and wishes—prior to an acute illness.

Take-Home Points

• Prospective discussions about what may occur as a patient's illness progresses reduce the likelihood of surprises. When patients understand the potential course of events and prognosis, it is easier to establish the goals of therapy.
• Hope for the best, but plan for the worst. Discuss with patients their preferences about resuscitation attempts, including in circumstances that might be reversible and iatrogenic. Otherwise, if the patient's wishes are unclear and an immediate life threat occurs, it may be prudent to treat the patient and continue discussions when the crisis is resolved.
• A daily checklist may help facilitate these discussions: establish prognosis, establish degree of involvement in decision-making, set goals, and revise therapies to achieve the goals.
• Carry out an ongoing discussion about what is happening with the patient's health and care.
• In end-of-life care, the patient's wishes remain paramount.

Albert W. Wu, MD, MPH Associate Professor, Health Policy and Management Johns Hopkins Bloomberg School of Public Health

Peter J. Pronovost, MD, PhD Associate Professor, Anesthesiology and Critical Care Medicine, Surgery and Public Health The Johns Hopkins University School of Medicine

References

1. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320:726-7.[ go to PubMed ]

2. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-94.[ go to PubMed ]

3. Casarett DJ, Stocking CB, Siegler M. Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic? J Gen Intern Med. 1999;14:35-8.[ go to PubMed ]

4. Casarett D, Ross LF. Overriding a patient′s refusal of treatment after an iatrogenic complication. N Engl J Med. 1997;336:1908-10.[ go to PubMed ]

5. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294-300.[ go to PubMed ]

6. Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 1997;349:309-13.[ go to PubMed ]

7. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18:71-5.[ go to PubMed ]