Introduction
The idea of the doctor is benevolent, There is nothing wrong, it is wrong to think but not to do it directly.
Source: YimaitongAuthor:The Running Emergency LiuThis article is published with the authorization of the author, and please do not reprint without authorization.
Elderly patients with advanced cancer, cachexia,
Can palliative care only be used as a slogan in the emergency room?
Case Review
Senior patient, male =”25851″ title=”Hypertension”>Hypertension, postoperative recurrence of adrenocortical carcinoma (multiple lung metastases, multiple abdominal metastases),
One day at 14 o’clock in the afternoon, the family members called 120, the main complaint/caller judgment: dyspnea worsened for 1 week 30 minutes/difficulty in breathing to be investigated, at 14:40 the patient was sent to the emergency department of the doctor again by ambulance.
On the same day, the medical records of the emergency department of the doctor showed: the patient’s visit time was 15:55, and the chief complaint: wheezing and anorexia 3 days, half a day of unconsciousness. History of present illness: The patient developed wheezing today, with anorexia, not wanting to eat, and the condition continued to worsen. Yesterday’s sanity gradually deteriorated. Today, I should not respond, and now I come to the hospital. The body temperature was 38.4°C when he came to the clinic, and he was transferred to our department after
The patient believed that after the patient was admitted to the hospital in an emergency, the doctor did not actively take effective treatment measures and delayed the treatment. The patient was treated until death. The patient’s death caused great mental and material damage to the patient’s family. In order to protect the legitimate rights and interests of the plaintiff, she brought a lawsuit to the court, requiring the doctor to pay 10,132.47 yuan for medical expenses, 600 yuan for nursing care, 300 yuan for hospital meals, 300 yuan for nutrition, and death compensation (Including the living expenses of the dependants) 1 581 583.3 yuan, funeral expenses 53 084 yuan, 40% of the above expenses is 658 399.91 yuan.
Case identification
The Forensic Appraisal Center was entrusted by the court to carry out appraisal on this case, and the forensic appraisal opinion stated: span>
(1) The medical party has the following medical errors in the process of diagnosis and treatment of patients:
1. The medical records are not standardized;
2. Insufficient information;
3.
4. Failure to give diuretic drugs in time to relieve Cardiac load, not timely consultation with cardiologist, there is insufficient;
5. Failure to correct anemia well , there are deficiencies;
6. Insufficient attention to the patient’s condition, incomplete consultation, and no diagnosis of the cause Pay attention;
7. Anti-inflammatory treatment is not given in time, which is insufficient.
(2) There is no relationship between item 1 of the above-mentioned medical fault behavior and the patient’s damage consequences. There is a causal relationship; there is a certain causal relationship between the 2nd, 3rd, 4th, 5th, 6th, and 7th items in the above-mentioned medical fault behavior of the doctor and the patient’s damage consequences, It is suggested that the medical prescription is the secondary reason.
The final degree of participation will be comprehensively determined by the entrusting party in combination with other evidence materials in this case.
The hospital does not approve the above appraisal opinions, and raises a written objection, requesting the appraisal institution to make supplementary explanations on the following issues:
1.What is the nature of adrenal cortical carcinoma tumor? How is the disease progression, prognosis and survival?
2.Combined with the patient’s past medical history, this At the second visit, the BNP result was 244pg/ml, and the lung CT results showed that there were multiple nodules in both lungs, and metastases were considered, which were larger and increased than before. Is it inappropriate to carry out symptomatic treatment for multiple metastases and cachexia in the lungs? If so, on what basis?
3.Rehydration and diuretic therapy from medical Is there a contradiction between principles and therapeutic effects?
4.The patient is considered by the identification agency to have cancer There are multiple hospitalizations in the late stage and there are multiple system obstacles. The appraisal agency thinks, can the hospital take measures to change this situation? If it can be alleviated and corrected to a certain extent, combined with the patient’s past medical conditions reflected in the identification materials, the appraiser thinks that this kind of relief can change the patient’s prognosis?
5.The patient was not autopsied, whether Affect the determination of accurate cause of death?
6.The appraiser believes that the patient’s family refuses Invasive rescue, in the case that ordinary oxygen therapy is difficult to maintain blood oxygen, and the vital signs are unstable, all invasive rescue is refused, etc. If no autopsy is performed after the death of the patient, whether it can cause the hospital to treat the patient’s lethal cause possible?
Instructions for a written reply issued by the accreditation agency:
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1. Adrenal cortical carcinoma is a malignant tumor, and complete cure of adrenal cortical carcinoma is difficult to achieve, because most lesions have invaded adjacent structures or far away at the time of diagnosis. metastases, and these findings suggest a poor prognosis. The 5-year survival rate of adrenocortical carcinoma ranges from 16% to 44%;
2. The hospital considers the patient Mainly “adrenal malignant tumor in advanced stage, (including lung) multiple metastases, and cachexia” are not inappropriate, but there are inappropriate in the process of diagnosis and treatment. Corresponding treatment, if the patient suffers from cardiac insufficiency, specialist treatment in cardiology should be performed;
3. Even patients with heart failure cannot avoid fluid replacement due to anuria or oliguria, so there is no contradiction between fluid replacement and diuresis;
< p>4. The prognosis of the patient cannot be changed, but the patient’s survival period may be prolonged through systematic active treatment. The patient should not directly give up active treatment and miss the opportunity to prolong the survival period due to the poor prognosis of the patient; span>
5. The cause of death of the patient is inferred from the relevant medical records and based on objective facts. Because the patient did not undergo autopsy, only clinical inference was made. In this case, the identification of causality has a certain impact;
6. The patient gave up all treatment and rescue, which affected the treatment, and did not perform an autopsy, which did have a certain impact on the cause of death, so the patient also assumed the corresponding responsibility.
Finally, the court did not agree with the doctor’s request for re-appraisal and adopted the secondary responsibility of the appraisal center (Compensation ratio is 20%~40%). The minimum judgment was that the medical party should compensate according to 20% of the liability ratio, which was calculated to be 337,749.59 yuan.
face Why does palliative care not work for terminally ill patients?
Emergency department is the hardest hit area for end-stage patients, especially in recent years, the incidence of tumor High, more common in patients with advanced tumors, and more common in patients with advanced heart failure and respiratory failure. The concept of palliative care was proposed many years ago abroad, and it has been introduced in China for a long time, and courses have also been started, but for emergency physicians, it is recommended to remove this concept.
After receiving N more than 120 terminally ill patients, Lao Liu took this The family members of these patients are divided into four categories:
The first category:I have a particularly filial piety, I don’t see my elderly suffer, I understand the prognosis but I can’t give up, my attitude is generally positive;
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The second category: Understand the prognosis, think that there is no objection to the treatment, but do not want to die at home. Feeling “almost”, I will be sent to the hospital, and I will wait for the card to be issued if everything is rejected.
The third category:Understand the prognosis, from I feel that I don’t want to be treated, but I am afraid that others will say that I am not filial. I will be sent to the hospital when my condition is serious.
Category 4:Everything is clear, Thinking of spending a little money in the hospital, and then making some big money, everyone understands.
The more I read, the more I talk about it, the more I get scammed, I slowly understand it. If it is an emergency department, there are only two treatment options for end-stage patients, go all out and give up all, don’t choose the middle option. In addition, the choice of the plan requires family members to be clear and signed.
For example, a late
All-out rescue and treatment, based on routine diagnosis and treatment and clinical guidelines, the inspection and the drug Medication, it is difficult to be at fault. When the family members give up everything, all examinations, and all treatments, the relationship of diagnosis and treatment will no longer be established.
But if they still ask for treatment, but they are not active, the family hesitates not to sign, not to take medicine, not to The doctor also felt that there was little hope for the examination and did not actively follow up. The treatment process shown in the final medical records will be prone to problems, and the appraisal experts will not use the poor prognosis as a reason for poor treatment.
Lao Liu’s practice is to monitor the patient, inhale oxygen first, and inhale oxygen as soon as the patient arrives.
If the family hesitates to give up completely, then they will try their best to treat them until the money is almost spent , agree to sign all waivers. Don’t let your family members say you don’t want to check, just give a little medicine, and just use some medicine to simply maintain it. This is not compassion, it is digging a hole for oneself.
Which family members of this case belong to, the friends make up their own minds, and what mistakes did the doctor make? , you can also analyze it yourself.
Experienced emergency physicians, Why does it sometimes become a hidden danger?
Back to this case, although the judgment does not introduce much about the patient’s condition, it can be It can be seen that the cause of the patient’s wheezing should be respiratory failure,
We can also learn from the opinions of experts:
The medical records of critically ill patients should be taken seriously Writing, content and format should be standardized;
The patient’s condition should be fully informed and critically ill Notices and medical communication records should be signed in time;
When receiving patients, the examination and treatment should be timely, and the treatment attitude and treatment plan should be positive;
Severe specialist diseases require timely consultation. If the diagnosis is unclear, a comprehensive consultation should be provided. All consultations require a doctor’s order and consultation records;
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Heart failure, respiratory failure, anemia, infection and other definite diseases should be treated with active symptomatic treatment first, and then according to consultation Specialist opinion to adjust treatment;
if the cause is not clear, should actively improve the examination and tracing Cause; is also a fault.
Many emergency physicians are experienced and The professionalism of the fault of the disease is also very high, and emergency doctors are quick-witted, quick-thinking, efficient, and practical. These are all advantages, but they have become hidden dangers in actual medical damage cases.
First of all, for patients who are basically not admitted to the hospital by specialist doctors and do not need specialist treatment, they will rarely be referred. Consultation, such as acute
Secondly, emergency physicians pay too much attention to effectiveness, check too little or not frequently enough, and end-stage patients are repeatedly checked What is the meaning of ? I can’t bear to torment patients, and the result is that the examination is not active and imperfect.
Finally, emergency physicians often do not treat terminally ill patients aggressively and comprehensively. The treatment of terminally ill patients is of little significance, and prolonging the life of a few days brings more pain to the patient.
Counselor
Xiang Heyman, Beijing Quan A lawyer of Zhi Law Firm (formerly Beijing Renchuang Law Firm), he has long been engaged in medical law research and practice, and has rich experience in medical law.
This case is from Beijing Court Trial Information Network
< /p>Editor in charge｜Su MuSource of cover image｜Yimaitong
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