When patients’ priorities conflict with those of their medical team; a challenging case of a bleeding patient and his dying pet

Abstract

We present an unusual case of an acutely unwell patient with an upper gastrointestinal bleed whose resuscitation efforts were delayed by the discovery of his, similarly, acutely unwell pet on the medical high dependency unit. We highlight the challenges this provided the clinical team and focus on the issues relating to patient safety, consent and multidisciplinary action which may be more relevant to daily clinical practice.

Background

A 52-year-old man with an upper gastrointestinal (GI) bleed had been monitored on the high dependency unit (HDU) for 2 days. The out-of-hours anaesthetic team became involved when a major haemorrhage call was put out following another further significant bleed. Assessment, resuscitation and treatment were significantly impaired by the discovery of his pet chicken on the unit, and the patient’s clear prioritisation of its life over and above his own.

This unusual case illustrates the difficulties inherent in acute, time-sensitive clinical emergencies when the patient’s ideas, concerns and expectations are at odds with those of their treating medical team. However, this case demonstrates that listening properly to those concerns, along with open, honest and empathetic communication between the medical team and the patient, allows for a mutually agreeable way forward to be found even in the most challenging of circumstances.

Case presentation

A midnight major haemorrhage call to the medical HDU rarely bodes well for the anaesthetic Senior House Officer’s (SHO) chance of a peaceful night. The patient in question was covered in a litre of fresh haematemesis. The medical team had gained intravenous (IV) access, blood products were on the way, and plans were underway for an urgent gastroscopy. It was then a nurse noticed the patient’s bag move.

‘What’s in your bag?’

A momentary pause.

‘A snake’, he responded, accompanied by vaguely unnerving laughter. Cue pandemonium as everyone fell over each other in a cowardly stampede for the door. While deciding which house officer was going to be sent to look in the bag, the problem was solved by a burly, topless patient in the opposite bed space who marched over and opened the bag himself before any medical staff could stop him.

‘IT’S A CHICKEN’, he announced proudly, as if on a particularly unusual labour ward.

It was immediately clear the chicken had seen better days. Being hidden in a dark, stuffy bag in a patient cupboard for 2 days dramatically increases one’s morbidity and mortality figures; as demonstrated by the chicken suffering agonal breathing while knocking on death’s door.

The chicken owner too realised the poor prognostic situation facing his beloved pet, and his demeanour shifted to one of passionate verbal and physical protection of ‘Chicken’. It became clear that as an emergency admission and with no friends or next of kin in the UK to look after his pet of 7 years, he saw no option but to bring Chicken with him. Undergoing a gastroscopy was evidently not top of his priority list, despite repeated advice that his own life was in danger. Security were called, senior nursing staff arrived and the rest of the HDU bay cleared of patients. A prior arterial blood gas had shown a haemoglobin of 61 g/dL and the need for urgent scoping was clear. But the patient continued to refuse; sitting on the floor, covered in blood, quietly cradling his dying pet, utterly overcome with grief.

On escalating to the anaesthetic registrar, we returned to find a rudimentary HDU bed had been made for the chicken out of an old saline storage cardboard box lined with Inco pads. With the offsite GI bleed registrar on the way in, a multidisciplinary discussion took place as to how to proceed. The problem wasn’t just the acutely unwell, yet physically imposing, patient not letting anyone within 6 feet of him, but whether he retained capacity to make decisions regarding his care. He appeared to understand that his own life was in danger. However he was adamant that we ‘treat chicken first’ before any proposed trips to theatre.

It was then that a poultry resuscitation attempt began. Oral rehydration was attempted via malt biscuits crushed in water. The patient requested the chicken be cannulated for IV fluid which was instantly vetoed given the lack of veterinary skills present in a hospital and amid talk of General Medical Council (GMC) referrals. However, the patient happy that his chicken was drinking, allowed for his blood transfusions to restart while remaining seated on the floor.

We retired once more to the corridor for further multidisciplinary team (MDT) discussions. Given Chicken looked slightly better, the RSPCA (Royal Society for the Prevention of Cruelty of Animals; who refused to come until morning) and a 24 hours vet on-call service (£750 call out fee at 2:00 in the morning) were called for further ideas. The site manager was expressing her understandable reluctance to charge this to the hospital when a howl of pain echoed through the ward. Chicken had breathed her last. ‘Probably refeeding syndrome’, the anaesthetic registrar guiltily remarked.

The patient was absolutely distraught. The GI bleed registrar had arrived and was trying to consent the patient for theatres, but the obvious pain of his loss meant that his own safety was of negligible value to him right then. And so, the anaesthetic registrar sat quietly with him on the floor and talked of chickens and the years they had spent together as ‘best friends’. A bargain was eventually struck. The patient would agree to go to theatre for a gastroscopy on condition that he could bury his companion in the morning. The anaesthetic registrar agreed and shook hands on it.

Treatment

The gastroscopy turned out to be unremarkable, other than the endoscopy nurses all wearing surgical masks to protect themselves from ‘Avian Influenza’. The patient was resuscitated under anaesthesia and returned to the HDU in a stable condition.

Outcome and follow-up

And so it was at 9:00, the anaesthetic registrar went to collect the patient from the ward with a trowel and garden fork in tow. Between a pair of oaks in a nearby park, the patient dug into the earth and began saying his goodbyes. Sadly, due to his relative anaemia, the patient could only manage a few minutes of digging before requiring a cigarette break, leaving the anaesthetist to scrabble in the dirt post night shift to the general bemusement of early morning passing dog-walkers.

Eventually Chicken was buried, a rudimentary cross made with two branches and prayers were said. A visibly relieved patient was returned safely to the ward, before the anaesthetic registrar went home to try and explain to his girlfriend why he had missed brunch and was covered in soil.

Discussion

This unusual case highlighted many challenges. Patient-centred care and holistic medicine are values at the heart of what we aspire to as healthcare professionals seeking to achieve good medical care as outlined by the GMC.¹ This case epitomised both. Our priority as clinicians is the well-being of our patients, and rightly so. But how often do we go the extra mile to find out what truly matters most to our patients? Of course, an animal on the ward is one extreme and many would cry fowl and demand ‘get that animal out of here right now’. But what was important to our patient? It is easy to fall into the trap of making paternalistic decisions in patients’ ‘best interests’, rather than explaining choices and letting patients decide for themselves.

Hospital cleanliness has long been a focus of healthcare planning and provision with the growth of antimicrobial-resistant organisms ever increasing. The ‘One Health’ initiative has outlined the importance of a multisectoral approach to tackle this including infection control which plays a significant role.² Policy makers have long acted on the importance of infection control to reduce infection rates,³ taking a multidisciplinary approach.⁴ However, implementing and monitoring such standards remains challenging and must not come at the expense of service delivery,⁵ as demonstrated by this case.

Regarding capacity, no healthcare staff member questioned the patient’s ability to understand, retain, process and communicate his decisions clearly until his unwell pet became involved. There was then an initial assumption that he must lack capacity in some respect. However, he understood the risks, communicated them to us and at that moment felt he would take a risk on life if it meant his companion stood a chance. This case was a vivid reminder of the sometimes stark differences between patients’ concerns and expectations versus those of healthcare staff. This case was thus an important reminder of capacity assessment whereby the GMC state:

You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with.⁶

This was an excellent example of the multidisciplinary team in action. Anaesthesia, medicine, staff nurses, matrons, theatre staff, healthcare assistants, porters and security came together to address an unanticipated and novel problem. Having discussed a variety of available options, we formulated flexible plans to achieve the best possible outcome for the patient given his personal tragedy. From resuscitation of both patient and his pet, to calling the veterinary professionals, to holding a funeral; many options were tried without ever putting all our eggs in one basket. The National Health Service comprises a wealth of experienced staff from all backgrounds. By working together, we used everyone’s strengths and ideas to the benefit of our patient.

Finally, patient safety is paramount in everything we do. Though there may be benefit in having domesticated animals visit patients occasionally,⁷ this is not the norm within most UK hospitals, with policies clearly stating pets are prohibited on hospital grounds. Though it was the failure to adequately check the patient’s property that led to the chicken not being discovered 2 days earlier, the MDT response was a calm and collected one. Or at least it was once snakes were excluded. On reflection, I think the challenge was handled well by our collective team. The alternative of physical and pharmacological restraint was potentially dangerous, ethically and legally dubious, and it was unnecessary given what was achieved with gentle negotiation, sensitive communication and genuine empathy for a patient’s individual situation.

The morning after the events, a critical incident report form was completed highlighting the difficulty faced by the clinical team addressing this uniquely challenging situation. As a result of the report, clinical staff were reminded of the importance of checking patient belongings prior to admission to avoid similar future incidents.

Two days later, the patient became acutely unwell again with a CT scan revealing a perforated duodenal ulcer. He was taken to theatre and, following a short ICU stay, made a full recovery being discharged home the following week. As described by Dr Stewart: ‘the best way of measuring patient centredness is an assessment made by the patients themselves’.⁸ Talking with the patient postrecovery as he expressed his thanks, I was pleased we met this criterion.

Learning points.

• Think outside the box when dealing with seemingly difficult patients or challenging scenarios.

• Use the thoughts and experience of the entire multidisciplinary team when stuck; even out of hours.

• Patient safety must always come first, no matter how difficult that may be to ensure.

• Remember in distressing situations, you and your patients are working towards the common goal of their health and comfort.