An untimely death

This was a case that I encountered on our last day of posting.

Mr.MH is a 72 year old man who is known to suffer from a right colon ca diagnosed in 2007. He had an anterior resection done with a formation of an ileostomy at that time. He also suffers from hypertension and diabetes mellitus for the past 6 years and was diagnosed with chronic renal failure last year which was attributed to these co-morbidities.

He presented currently with symptoms and signs suggestive of acute pyelonephritis for 3 days prior to admission. Examination revealed renal angle tenderness as well.

Renal profile showed severe renal impairment with hyperkalemia. Ultrasound revealed a picture of bilateral obstructive uropathy. A CT Urogram was planned.

He was only managed with a Dextrose Insulin and Potassium regime to correct his hyperkalemia. No ANTIBIOTICS were prescribed.

On the third day of admission, he deteriorated and past away.

Issues that I faced :

1. The CT urogram was suggested on the first day of his admission and the patient did not agree to it. However it took almost 2 days for the doctors to get a consent. I managed to witness one of the attempted consent. In my opinion, that attempt underlines the fundamental of medicine that is COMMUNICATION. The patient clearly did not understand what the CT urogram was and what for. The doctor's haphazard explanation of CT Urogram would drive any patient away.

2. He did not record any fever after being admitted. This was the doctor's explanation for not prescribing antibiotics. I feel the doctor failed to recognise that acute pyelonephritis can have varying presentation and non-specific symptoms. Fever is usually present but it may not be all the times. An empirical antibiotic therapy should be initiated pending results of blood/urine cultures.

3. Once the patient stopped breathing and became pulseless on the third day, CPR was initiated. Chest compression was started while intubation was done to secure the airway. All other protocols were followed. However the cardiac monitor showed ventricular fibrillation. The doctor failed to notice this and kept ordering chest compression to be continued. A DEFIBRILLATION needs to be done to shock the heart out of ventricular fibrillation. I feel its a big error on the doctor's part for not picking up the rhythm on the cardiac monitor.

4. While this was going on, another doctor came and ordered to stop resuscitation as he/she obtained a DO NOT RESUSCITATE from his wife during this ordeal.

Now I may not be familiar with letter of the law, but by definition, a DNR is an ADVANCE DIRECTIVE that is to be followed when a person's heart or breathing stops and they are unable to communicate their wishes to refuse treatment that could allow them to die. As rightly pointed out by my colleague, can a DNR be obtained while resuscitation is being performed? I would like an expert opinion on this matter.

I think not. But I may be wrong.

The official cause of death was advanced colon cancer. I do not agree at all at this COD. No CT scan was done previously to confirm a recurrence or metastasis. How can one confirm this as the cause with no evidence? My cause of death would be Acute Renal Failure and Sepsis secondary to Acute Pyelonephritis.

Though the prognosis for this patient was bad to begin with, the eventual outcome did not surprise me with all the mismanagement and haphazard approach of treating this patient. I think being critical of the doctors is important. But equally so, is our approach and competency in knowing what we are executing.