BY CRAIG KLUGMAN, Ph.D | LIFE MATTERS MEDIA CONTRIBUTOR
This past week appears to have been “advance directive week” on television. First, on the rebooted X-Files, Dana Scully finds her mother’s advance directive. Second, a Chicago Med physician ignores not only a DNR, but a patient’s clearly stated wishes not to be resuscitated. One of these storylines showcases a model of a good surrogate decision-maker. The other reveals an arrogant doctor who blatantly ignores patient autonomy.
The X-Files (Season 10, Episode 4) finds Agent Dana Scully at her mother’s bedside. Mom is unconscious, intubated, and on a ventilator. Dana instructs her brother to board a plane, as it was their mother’s wish to remain on a ventilator so that her children could gather.
However, a nurse tells Dana that her mother completed a new advance directive in the last two years; this form states her wish not to be intubated. She also wanted a DNR. This new document surprises Dana, who wonders why her mother would change her mind and not discuss her preferences with her (besides being an agent, Dana is a physician). The nurse explains that just because they extubate her mother does not mean that she will die immediately. Dana had wanted to keep her mother alive; she had hoped that her family could have time to say goodbye and “ask the little questions.” She also had wanted to understand why her mother changed her care choices. Despite her personal concerns, Dana acts as a good surrogate, making the decision that her mother wanted. Her mother is extubated and dies only after hearing the voice of her long estranged son on the phone.
Mrs. Scully’s dying was done surrounded by her daughter and ex-son-in-law. She offers a life lesson to her daughter regarding the value of family and the ideas that we create. Her death is peaceful, allowing for closure and for her wishes to be honored.
The opposite occurs on Chicago Med (Season 1, Episode 109). An unconscious mother arrives at the hospital after a bad fall, resulting in bruises and a broken arm. As she has been receiving cancer treatment for four years- including experimental therapy- this patient has a DNR order. Her husband and daughter do not want to see her go, and her husband is not a strong advocate. He tends to waffle, failing to make decisions. The patient, however, is strong in her beliefs. She has clearly documented instructions to providers that she is done: under no circumstances should they resuscitate her.
A young physician, Dr. Will Halstead, lost his mother to cancer when he was a child. While flirting with a pharmaceutical representative, he learns of a “promising” experimental trial for a drug targeting the same cancer affecting this patient. He even manages to secure a space for this patient in the trial. When the patient declines this opportunity, Halstead attempts to convince her spouse to override her DNR so that she may enter.
Her husband indicates that he does not want to lose his wife. When she codes, Halstead performs a resuscitation- despite his colleagues’ instructions to stop. As he later states, his “job” is to save his patients. The resuscitation restarts her heart and demands an intubation. This patient is now likely to experience exactly the kind of death she had hoped to avoid.
When she finds herself intubated, the look in her eyes reveals how unhappy she is. Her discontent is proven further when her family sues the hospital and pursues battery charges against Halstead.
Halstead is reprimanded by the hospital administrator; however, the physician will neither be fired nor suspended because the institution must maintain the appearance that nothing is wrong. However, after the case is complete, he will likely lose his position. Rather than express humility or remorse, Halstead states confidently that this family will drop their suit after the trial saves her life.
In this instance, a doctor believes in the life-saving power of a clinical trial without such an aim. His magical thinking causes harm to his patient, overriding her autonomy. Halstead acts on his own because he feels he has the power to save her. He wants to “save” another child from experiencing the same loss he once experienced as a boy.
The public often learns about medicine and health from popular media. For those lucky enough to have avoided many medical experiences, these shows may be all they see of this world. Although Halstead acted unprofessionally (unethically, and maybe even illegally), the fact that he is being punished for such actions demonstrates the importance of taking end of life choices seriously. How these two shows ultimately address the repercussions of these deaths remains to be seen. If Halstead turns out to be right and his patient survives, then Chicago Med will once again have harmed the cause of medical ethics education among the public. However, if he is punished, the cause of education will have been furthered.