HM Medical Clinic

Hprb.gov.bc.ca

Suite 900, 747 Fort Street Victoria British Columbia
Telephone: 250 953-4956
Health Professions Review Board Facsimile: 250 953-3195
Toll Free: 888 953-4986
(within BC)
Mailing Address:
PO 9429 STN PROV GOVT
Victoria BC V8W 9V1
DECISION NO. 2010-HPA-0201(d); 2010-HPA-0202(d); 2010-HPA-0203(d); 2010-
HPA-0204(d)
(Grouped File: 2011-HPA-G04)
In the matter of an application under section 50.6 of the Health Professions Act,
R.S.B.C. 1996, c. 183, as amended, (the "Act") for review of a complaint disposition made
by an inquiry committee
BETWEEN:
COMPLAINANT
The College of Physicians and Surgeons of BC Four Physicians and Surgeons REGISTRANT
Marilyn Clark, Panel Chair REVIEW BOARD
Conducted by way of written submission concluding on March 9, 2012 APPEARING:
For the Complainant: Self-represented For the College: Shaleen Kanji, Counsel For the Registrant: Terrence L. Robertson, Q.C., Counsel DECISION
Upon considering the application of the Complainant under Section 50.6 of the Act, I confirm the disposition of the Inquiry Committee. The Complainant, a Registered Nurse in the United States, has applied on behalf of her deceased brother (the Deceased) whom she claims, during a period from November 4, 2008, until the date of his death in hospital on May 7, 2009, was denied appropriate medical care and when medical care was provided, it was often delayed. The complaints further allege inappropriate medications, inaccurate charting and/or reporting, disregard for the provisions in the Deceased's Representation Agreement and even discrimination on the basis of age, race, disability, and diagnosis. DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
The Complainant's original application to the College implicated five Registrants. When applying to the Review Board for review of the College's response, only four Registrants were brought forward for review. In the case of two of the Registrants, there was a direct accusation of the practice of euthanasia, and in the case of the other two Registrants, indirect references by such assertions that "(the Deceased) was stamped de facto DNR (Do Not Resuscitate) by all the physicians." The Deceased was a very sick man who presented with a number of problems including, but not limited to, paraplegia, lung cancer, COPD, osteomyelitis, diabetes, asthma, and chronic infection. The issues to be determined are twofold: was the investigation conducted by the College adequate in regard to the complaints filed against each of the Registrants; and was the College's disposition in each instance reasonable? BACKGROUND
The Deceased came from a close-knit, deeply religious family, the fourth child of He had suffered an accident in 1971 which left him a paraplegic. His medical history when he was moved to the Extended Care facility in November, 2008, was summarized by Registrant 1 based on the Discharge Summary provided by the Rehabilitation Hospital, as follows: Right ischial tuberosity debridement and flap repair, osteomyelitis treated with IV Imipenem and Vanomycin. He had a grade one pressure wound of the natal cleft, hypoglycaemic episodes, multiple urinary tract infections with multiple organisms, gastroesophageal disease symptoms, and bladder stones. He was a full code. His lung cancer was to be followed at the cancer agency by (an oncologist) and he apparently had a 50:50 chance of recurrence. He was noted to have ongoing complaints of abdominal bloating, dyspepsia and low haemoglobin. There was no weight loss and no evidence of blood loss or infection. An upper endoscopy and abdominal CT were normal. His multiple urinary tract infections were difficult to treat due to multiple organisms growing, and so treatment was limited to those infections which caused symptoms indicative of active infection as opposed to colonization only. His chronic osteomyelitis of the inferior pubic ramus and right ischial tuberosity had a full 12 week course of IV imipenem and Vancomycin, and it was felt unlikely that this area could be effectively treated with further IV antibiotics. They also made mention of significant family complications due to his "impending divorce and lack of family members around and support." Registrant 1
Registrant 1 was the physician responsible for the Deceased's care from the time he was transferred from the Rehabilitation Hospital to an Extended Care Facility on November 4, 2008. DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
The Complainant alleges that when the Deceased developed petechiae and then oral thrush, Registrant 1 did not take medical action. The Complainant further accuses Registrant 1 of lying about the non-availability of vancomycin in the extended care formulary. The Complainant claims an RN said "it is available in the hospital formulary and that there are patients taking the medication now". The Complainant even offered to go to the pharmacy with a prescription to purchase zyvox. According to the Complainant, this is an example of the discrimination that took place with respect to the treatment of the Deceased, as she asserts "[the Deceased] did not get the correct and appropriate antibiotic that should have prevented/averted the spread of infection to his blood stream". In response, Registrant 1 states that zyvox is not vancomycin, and goes on to clarify that "oral vancomycin is not used to treat skin infections, rather its use in the oral form is limited to the treatment [sic] enterocolitis and pseudomembranous colitis caused by clostridium difficile. This was in fact, the case on our floor, as there was another patient with chronic c. difficile colitis requiring oral vancomycin." Registrant 1 goes on to state: Vancomycin can be used intravenously to treat skin infections, however, (at our facility), extended care does not meet the staff requirements to provide intravenous medications and thus does not offer this service. Finally, (as the Deceased) was Vancomycin Resistant Enterococcus (VRE) positive this would not have been an optimal choice. Vancomycin is reserved only for severe soft tissue infections not responding to other antibiotics. It is generally considered a drug of last resort due to emerging drug resistance and its toxicity. It is further stated in the complaint against Registrant 1 that she verified the level of care prior to the Deceased's transfer to the hospital. "The Deceased was stamped de facto DNR by all the physicians." With respect to end of life decisions, Registrant 1 responds: This patient remained competent to make his own decisions throughout the time he was under my care. Although I was not initially aware [the Deceased] had a Representation Agreement, having had a chance to review it, I would like to bring your attention to point number 2a, Coming Into Effect. Please note, this point says the Agreement would only come into effect if he was unable to make decisions independently about his health care, personal care, or financial affairs due to lack of capacity. Registrant 1 further states with respect to the end of life decisions: Around February 19, 2009, [the Deceased's] current health status was discussed with both him and his sister over a couple of conversations. I explained the seriousness of his condition. I explained that given his severely compromised respiratory status and his overall deterioration, the chances of him surviving a full code in a meaningful way following an arrest were slim to none. I explained what an admission to an intensive care unit with intubation at the end of his life would be like. We talked about maintaining his dignity through the end of his days, however long they may be. I explained we would continue to take the best care we could of him and would still treat his symptoms and arrange for DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
transfer to [the Hospital] if he deteriorated. [The Deceased] agreed to a level three code status. I found him to be entirely competent to make this decision. With respect to the accusation of discrimination, Registrant 1 states "at no time did I discriminate against [the Deceased] or his representatives based on his race." Registrant 2
Registrant 2, a surgeon, was asked by the Emergency physician to assess the Deceased's anal rectal abscess when the Deceased was admitted to hospital on April 22, 2009. Registrant 2 attended the Deceased along with the on-call surgical residents and students. The Complainant asserts that Registrant 2 asked the residents who accompanied him for their assessment and recommendations. One of the residents suggested that a referral be made to the plastic surgeon who had performed the flap surgery in 2008, "culture and sensitivity of the peri anal area, drain the abscess and antibiotic administration". The response by Registrant 2 to this suggestion, according to the Complainant was "There is no need to refer the patient to [the plastic surgeon]." The Complainant asserts that Registrant 2 "could not and would not listen to his surgery residents". In his response, Registrant 2 discusses his approach as the senior leader of the team, involving his trainees in the decision-making process and then arriving at a decision at the bedside. He believes the resident who made the suggestion was not aware of the distinction "between sepsis arising from a decubitus ulcer versus that arising from an anorectal abscess" and used the opportunity for a teaching moment. This event, he believes, was misunderstood by the Complainant. The Complainant goes on to say that Registrant 2 "prescribed oral Cipro, oral Flagyl due to the Noro virus". The Noro virus was present in the extended care facility where the Deceased had been residing prior to going to the hospital emergency. The Complainant reports that when she heard the names of the medications that were being recommended, she showed Registrant 2 "the results of the culture and sensitivity from previous test results. He totally ignored the results". She asserts Registrant 2's decision to prescribe alternate antibiotics other than those prescribed "allowed progress of infection that could not be averted." Registrant 2 states, with respect to the reference to the Noro virus: "This is neither evidence-based, nor my practice." The Complainant asked Registrant 2: …where the abscess that appeared in the Cat Scan that was not present from the previous Cat Scan. (Registrant 2) showed me the Cat Scan film and discussed with me the fistula like a pinpoint about two inches long and said it will disappear and close up as it heels. (Give me a break. How would/could a fistula heal up inside the body? It would/could only close if surgery is performed. That was my thought as I was listening to him.) THIS IS REPEAT NEGLIGENCE AND MEDICAL MISJUDGMENT FROM THE PHYSICIANS – OVER AND OVER AGAIN. DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
The Complainant states that the Deceased is "resistant to Cipro." Even though he takes millions of Cipro tablets for the urine infection, peri-anal abcess [sic] or any kind of infection, he will not heal up from the infection because the bacteria is resistant to Cipro. After the IV antibiotics were given, [Registrant 2] concluded that there is no need for hospital admission. I had doubted the medical judgement because [the Deceased] is beginning to have the infection from the anal area where the flap is. His physical condition is telling so and the lab results reveal it so. His lymphocytes are so low and the platelets was high – indicating that the body is holding up to compensate the physiological insult going on. Where I am trained, Physicians and RNs are trained to visually assess patient while comparing the physical assessment with the laboratory results. In response to the Complainant's assertions, Registrant 2 acknowledges the concern that was expressed by her. First with respect to the surgical management, incision and drainage was not necessary for this perianal abscess. The abscess had already decompressed as evidenced by clinical and laboratory criteria. There was no evidence for necrosis which required debridement. Registrant 2 goes on at length defending his selection of antibiotics. . [the Deceased] was acknowledged to be an immune-compromised and frail person due to his other medical problems. For this reason, even though the abscess had drained, a recommendation was made for antibiotics. As no cultures were available at the time, empiric therapy was recommended. This empiric therapy was chosen based upon the bacteriology that is known for anorectal-sourced infections. Typically, there bacteria consist of enerobacteriaceae, staph aureus and group A streptococci as well as anerobic gram negative cocci, bacteroides and anerobic gram negative bacilli. Based upon this known spectrum of bacteria, ciprofloxacin is a good choice for enterobacteriaceae and Flagyl is a good choice for anerobic gram negative cocci and bacilii. Furthermore, the presence of a chronic wet ischial tuberosity ulcer is notoriously associated with pseudomonas type of bacteria for which Cipro is an ideal choice. The Complainant is critical of Registrant 2 for not offering surgical interventions which might have allowed the progress of the infection to be halted. Registrant 2 states that since "the abscess had already decompressed", surgery was not indicated. Rather, he responds, that the Deceased's "overwhelming sepsis were due to the lack of antibiotics to which bacteria were sensitive", which was confirmed by the "CT evidence more than one week later (May 1) of air in both his bladder wall and hip joints which is consistent with anerobic gas forming microorganisms rather than the antibiotic-resistant organisms". Claims of discrimination by the Complainant on the basis of disability, the Deceased's DNR status, and race are categorically denied by Registrant 2 and, in this regard, he responds: Indeed, I attempted to extend respect and human dignity to [the Deceased] in generous ways. First, I made myself available directly at his bedside accepting the need to take added steps to make personal contact despite the physical barriers for isolation precaution given his chronic infection state. I generously involved [the Deceased's sister] in the DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
discussion of his management and I shared direct information such as imaging with her in order to explain patiently the rationale for [the Deceased's] diagnosis and treatment and hoped that this would provide this man optimized comfort and information under extremely difficult and unfortunate circumstances. Registrant 3
On April 29th, 2009, the Deceased was readmitted to hospital under the care of a physician not the subject of this review. On May 1, Registrant 3 took over his care as the attending physician until the Deceased was transferred to the Intensive Care Unit on May 4. The complaints leveled against Registrant 3, including "He practiced euthanasia", are broad-ranging and damning: Registrant 3 failed to treat [the Deceased] in a timely manner by denying and delaying medical treatments, blood transfusion, administration of albumin, nutrition, oxygen delivery, administration of antifungal medication for the presence of oral thrust [sic] . . He violated the code of professional ethics imposed by the British Columbia Canada Medical Association and Canadian law by ignoring the Representation agreement with Limited and General Powers. He violated the Patient Bill of Rights, discriminated [sic] [the Deceased] due to race, age, disability and social status, rendering to health care rationing. The patient passed over to Registrant 3 on May 1 was in the following condition, according to Registrant 3: He was 66 years old and had longstanding paraplegia due to trauma incurred in the l970's. His paraplegia had been complicated by chronic sacral ulcer, which had been previously treated with a skin flap procedure by a plastic surgeon; chronic osteomyelitis of his pelvis; and urinary tract infections. He was colonized with both methiciliin-resistant Staphylococcus Aureus and extended-spectrum beta-lactamase producing gram negative bacteria. He also had diabetes and chronic obstructive pulmonary disease due to smoking. In 2007, he was diagnosed with lung cancer, with mixed small cell and non-small cell pathology. He went on to have surgical resection of the Cancer in October 2007; due to his chronic infections, he was not a candidate for adjuvant chemotherapy. He developed recurrent disease in his central chest along with a pleural effusion in 2009, and had palliative radiotherapy to the chest in March 2009, with shrinkage, but not resolution, of the mediastinal nodes. . his medical oncologist felt that the recurrent tumor was most likely small cell, which when recurrent – especially when chemotherapy is not possible – carries a grave prognosis. Once again, the view of the Complainant, "no action was taken to improve his homeostasis", and that of Registrant 3, "[the Deceased] was receiving aggressive and appropriate IV antibiotic therapy, IV fluids, and a thorough work-up for potential surgical source control of sepsis", are different. With respect to end of life decision-making, Registrant 3 states: Another goal was to determine the appropriate level of care, recognizing that in this situation, many cancer patients would wish palliative, not life-prolonging care, and that ICU DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
or critical care measures would likely only lead to life being prolonged on a ventilator, without hope of returning to his previous level of health. The Complainant alleges that from the time the Deceased was transferred to the care of Registrant 3, the Deceased "became paler and paler. All his blood laboratory result were critically abnormal. I begged and pleaded to (Registrant 3) to please transfuse blood to [the Deceased] in order for him to fight the infection, decrease his general body swelling, improve his electrolytes and improve his immune system." In response to the allegations from the Complainant, Registrant 3 states: I asked for bloodwork to rule out disseminated intravascular coagulation and ordered serial complete blood counts. As I stated in the chart, I was prepared to transfuse if his hemoglobin dropped lower than 70; this threshold was used in the TRICC trial of critically ill patients who were not bleeding and who did not have known cardiovascular disease, and has been shown to be a [sic] superior to a strategy of transfusing when the hemoglobin is less than 100. To the accusation that "ALL COMMUNICATION FAILED. THERE WAS NO PLAN OF CARE", Registrant 3 states "In fact the chart shows there was ongoing communication with the subspecialty services and the plan was clearly laid out, namely, to treat with appropriate antibiotics, address the pancytopenia, and search aggressively for source control options." Registrant 4
Registrant 4 was a resident in the Intensive Care Unit responsible for the care of the Deceased from May 4 until his death during the afternoon of May 7. The Complainant asserts that Registrant 4 practiced euthanasia; that he "abandoned his professional medical responsibility"; that he "violated the Human Rights based on [the Deceased's] disability, race and social status"; and that "ALL DOCTOR's EFFORT WERE FOCUSSED TO DNR INSTEAD OF TREATING [the Deceased]". Much of the complaint, with respect to Registrant 4, focuses on the lack of treatment provided by the other registrants subject of this review, which, had they, in the opinion of the Complainant, provided appropriate, timely treatment, the Deceased would not have had to be admitted to the Intensive Care Unit. However, given that the Deceased was under the care of Registrant 4, the very real issue was the use of artificial means to keep him alive, how long that should continue and who should make the decision to withdraw those artificial means. Registrant 4 responds to the accusation of practicing euthanasia: During his stay in the intensive care, the ICU team and the family agreed that the aggressive and invasive artificial life support was not of any benefit to [the Deceased] and that it caused significant discomfort in itself. It was commonly decided with the family that the support should not be increased, and that when the family was ready, we would remove the mechanical ventilator and the vasoactive agents, ensuring that pain and anxiety were treated adequately. DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
The nursing notes illustrates [sic] that the family was aware and active in the process of end of life care: the family supported that the ventilator be discontinued at 11:35 and the endotracheal tube be removed at 14:30. [The Deceased] died 3 hours and 25 minutes after the comfort care measures were initiated. The cause of death was septic shock secondary to emphysematous cystitis and hip osteomyelitis. In [the Deceased's] case, life support was withdrawn as agreed. Natural death ensued, from septic shock. This does not constitute euthanasia but rather termination of life support measures. With respect to the assertion that Registrant 4 abandoned his medical responsibility, he states: I sincerely believe that I and the rest of the ICU team provided adequate, caring, and humane comfort care measures to [the Deceased] who had previously expressed wishes not to be resuscitated in the context of palliative cancer treatment and chronic severe infection. On the morning of May 7th, I was an advocate for [the Deceased]; ensuring his wishes were followed by altering our therapy to comfort measures. This is not abandonment; rather it is compassion and advocacy. As to the accusations of human rights violations and discrimination, Registrant 4 makes assurances that "factors such as disability, race and social status never play a part in any of my clinical decision making". There are differences as well with respect to the issue of not providing resuscitation. The Complainant in each of her complaints accuses the physicians involved in the Deceased's care of being more interested in obtaining a DNR status than providing care. Registrant 4 responds that: After my initial assessment of [the Deceased], all relevant specialists had already been consulted and mentioned the poor prognosis and the absence of reversible condition. Also, in the last note available in which [the Deceased] was described as being competent, he agreed not to be resuscitated in case of cardiac arrest as it would not be beneficial. Many other physicians had voiced concerns about the futility of invasive support in that case, and that they wanted to be non-malevolent and provide humane end-of-life care. Final y, the ICU team wanted to respect the patient's autonomy as this was discussed previously with his oncologist. The family's insistence that his wishes had changed lead the ICU team to accept to resuscitate the patient in the context of the critical in extremis situation. The goal was to obtain time to inform the family, establish a relationship, and reassess the patient's wills. I did not coerce the family into accepting not to provide resuscitation; rather I reinforced the previously established facts that aggressive care was not in [the Deceased's] best interest and ensured that the family realized that he had understood and agreed with this. DISCUSSION AND ANALYSIS
There are a number of factors that appear to have led to the polarizing positions of the Registrants and the Complainant and her family. First among these is the Representation Agreement. DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
The Representation Agreement and End of Life Decision Making
A Representation Agreement provides an opportunity for a person to name one or more persons to be their representative to help manage that person's affairs and, if necessary, to make decisions in case of illness, injury, or disability. According to Section 16 of the Representation Agreement Act, a representative's first responsibility is to assist the person to make their own decisions. The Nidus Registry (a personal planning resource) fact sheet describes the responsibility of the representative as follows: When making decisions on the adult's behalf, a representative must stil check with the adult first to determine the adult's current wishes. If the current wishes cannot be determined or are not reasonable to follow, then any pre-expressed wishes must be followed – things that the adult said or wrote down when they were capable. If these are unknown, then decisions are made according to the adult's values and beliefs. The adult is always at the centre of all decisions. Only as a last resort does a representative impose their opinion of what is best for the adult. The Deceased's Representation Agreement provides in Section 2 entitled Coming into Effect as follows: (a) This representation agreement will only be in effect if I am unable to make decision independently about my health care, personal care, or financial affairs due to lack of capacity. (b) A declaration completed by my [sic] either of my physicians, [Registrant 3] or [another physician] of [City], British Columbia, will be sufficient proof that I am unable to make decisions independently about my health care, personal care, or financial affairs. Having appointed the Complainant, two other sisters and a brother as his health care representatives, the Deceased provided for the following in his representation agreement: My instructions about-end-of-life treatment I choose not to give any further instructions. My representatives are familiar with my values, wishes, beliefs and will follow them, so I do not give and [sic] specific instructions about "end of life" treatment or any other issues in this document. It is my opinion that the failure to leave instructions contributed to the difficulties at the end of the Deceased's life. Registrant 1 states that after a discussion on or about February 19, 2009 in regard to his compromised health condition and the realities of admittance to an intensive care unit with intubation, "[The Deceased] agreed to a level three code status. I found him to be entirely competent to make this decision." She states further "A physician must respect the wishes of the patient even if they are in conflict with the wishes of his family." DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
Registrant 3 writes that on May 4: It was clear that he was nearing requiring ICU care to prolong his life. After having spoken with his oncologist and reviewed the chart, I was not confident that [the Deceased] would want critical care measures taken to prolong his life, as I felt his underlying comorbidities were such that he would not be weanable from a ventilator . . none of us believed that intubation and ventilation would accomplish anything other than prolonging life on a ventilator, and I think there is fair written documentation that [the Deceased] himself did not wish that. I informed his sisters of my professional opinion regarding [the Deceased's] likely outcome if he were intubated and ventilated (prolongation of life but no hope of survival outside the unit); they were adamant that he should remain a "full code". Registrant 4 writes: . two respirologists had seen [the Deceased] over the last weeks and had suggested that the prognosis of recovery was poor and they did not think it would be in the interest of [the Deceased] to receive cardiopulmonary resuscitation in case of decompensation. The patient, at that time conscious and competent, had accepted not to have aggressive resuscitation and CPR during that hospitalization. The Oncologist responsible for treating the Deceased wrote following the Deceased's transfer to ICU, …in light of all that is going on, I do not think aggressive measures are appropriate in his situation. In my prior discussions with [the Deceased] in clinic when he had started to deteriorate, we had discussed code status. He did not desire aggressive measures to be pursued and in light of knowing his own wishes, I think that pursuing further aggressive measures would not be in his best interest. There is other documentation in the chart that provides a similar story: the Deceased did not want aggressive measures used to extend his life. However, there is also a March 8, 2009 hand-written document in the Record and it reads as follows: To the Medical Staffs involve in the Care of [the Deceased] [the Deceased's] family dynamics We, sibling, nieces/nephews, care of [the Deceased's] well being. We will be and must be included in decision makings with regards to the treatments in order to meet the optimal palliative objectives and care of [the Deceased]. [signed by the Complainant] I [the Deceased] authorize my siblings to be included in the decision making of my treatment to meet the optimal palliative care and open communication with them. [signed by the Deceased] record to my chart. DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
The Level of Intervention Form that all extended care facilities require be filed was completed on November 6 and signed by Registrant 1, after discussion with the Deceased. At that time, he elected level four which includes transfer where medically appropriate to an intensive care unit and the use of a respirator. That was changed on February 19 to level three by Registrant 1. An unidentified person added, in hand-writing, on March 20, 2009, "The Deceased is level 4 with full code." Other Factors that may have Contributed to the Controversy
The failure to provide instructions in the Representation Agreement was not the only factor that may have contributed to the conflicts that occurred at the time of the Deceased's death. The family's religious beliefs stemming from a strong Catholic faith contributed to their end-of-life decision-making and their inability to come to grips with not doing everything possible to extend their brother's life. The Complainant wrote: [The Deceased] and his family are devout catholic. [The Deceased] and family, as catholic, we do not practice assisted end of life. Bodily pain and suffering is a form of indulgence but we take it gracefully. The bodily pain and suffering did not even project in [the Deceased's] face because he took it spiritually. Metaphysically speaking, it contributes to better physiological changes like secreting endorphins. Registrant 4 claims "religion never plays a part in any of my clinical decision making." He also refutes the suggestion that "assisted end-of-life" played a part in [the Deceased's] end of life. He states clearly "life support measures were withdrawn and there were no maneuvers of any kind to hasten the dying process. The family was present during the whole process. They supported every step of the process, including removal of the mechanical ventilator and of the breathing tube." The hospital records indicate over and over the interventions of the family and the opportunities the family members took to disagree with and make recommendations to the professionals involved in the care of their brother. Both the Complainant and her sister are nurses in the United States and they actively monitored the care provided to their brother on a daily basis. The Complainant and her sister continually second-guessed the decisions of the medical specialists. The nurse Complainant presents at every turn as having superior knowledge to all of the physician specialists involved in the care of the Deceased. Another factor that may have contributed to the belief by the family that the Deceased was not being treated so that he might recover was the referral, by the care givers, to Risk Management. The Complainant provides a Risk Management Bulletin from the Health Authority which states "There is no obligation to offer care simply because it is demanded, however demands for care that the Team does not consider appropriate should be addressed respectfully." The Complainant highlights the options available: Accept the care that IS offered by the team (in many cases this will be supportive/comfort care) DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
Arrange for transfer to another provider/hospital, unless unsafe to do so Seek Court intervention to compel provision of care This referral to Risk Management contributed to the Complainant's belief that care was being rationed: The only collaboration I saw was the DEFACTO DNR AND THE DECISION BASED ON THE RISK MANAGEMANT ALGORITHM. What is the business of the risk management algorithm in the treatment of disease except to RATION THE HEALTH CARE. HOW COULD ONE DEPARTMENT OR ONE TEAM OF [THE HEALTH AUTHORITY] DECLARE A PERSON DENIAL OF CARE BASE ON THE FACT THAT "HE HAS CANCER". The Complainant's correspondence contains what can only be described as rants and if the care providers were treated in person to these rants, disparaging remarks and disagreements, it is no wonder there were conflicts. End-of-life decision making is fraught with complexity: emotional, religious, legal, family wishes and medical realities. It appears in this case, that family members found it difficult to accept the decision the Deceased would have made for himself rather than the decision that they may have made for him or themselves. REMEDY SOUGHT
In the case of each of the Registrants, the Complainant is asking the Review Board to suspend their license to practice medicine with suggestions in each case as to further training or exposure that she would recommend. The Inquiry Committee does not have such powers, see s.36(1) nor does the Review Board. The Review Board is limited by Section 50.6(5) and 50.6(8) of the Act to considering the adequacy of the investigation and the reasonableness of the disposition: . the review board must conduct a review of the disposition and must consider one or both of the following: (a) the adequacy of the investigation conducted respecting the complaint; (b) the reasonableness of the disposition. On completion of its review under this section, the review board may make (a) confirming the disposition of the inquiry committee, (b) directing the inquiry committee to make a disposition that could have been made by the inquiry committee in the matter, or (c) sending the matter back to the inquiry committee for reconsideration with directions. DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
ADEQUACY OF THE INVESTIGATION
The Record in this matter exceeded 1400 pages. The College had for review the extensive letters of complaint from the Complainant dated January 31, 2010, March 29, 2010, April 5, 2010, and May 20, 2010, hundreds of pages of hospital records including lab reports, nurses notes, social worker notes and even the notes of the chaplain after a visit. In addition, there were the responses from each of the four Registrants, a response from the Oncologist responsible for the Deceased's care at the Cancer Agency and a response from the fifth Registrant who was not the subject of this Review. Upon completion of their review, the Inquiry Committee advised the Complainant that they had concluded "your brother was provided with appropriate care and your accusations against the physicians who provided him with that care cannot be substantiated". They clarified, in their response, some factual errors: "infections do not cause diabetes."; they commented on the use of blood transfusions in people with pancytopenia; and, finally, the cause of death: "While you repeatedly state that his ultimate demise was not from lung cancer, this is incorrect, in that the general debilitation caused by the cancer led to his respiratory failure and the overwhelming infection which he had to contend with in his last days." The Complainant disagrees with these statements. The Inquiry Committee also commented on the contentious issue of the Representation Agreement. The Review Board has articulated in Decision No. 2009-HPA-0001(a); 2009-HPA- 0002(a); 2009-HPA-0003(a); 2009-HPA-0004(a) at paragraph [97] the extent to which a College must investigate a complaint: A complainant is not entitled to a perfect investigation, but he or she is entitled to an adequate investigation. Whether an investigation is adequate will depend on the facts. An investigation does not need to have been exhaustive in order to be adequate, provided that reasonable steps were taken to obtain the key information that would have affected the inquiry committee's assessment of the complaint. In my review, I find nothing lacking in the College's investigation. They had complete responses from each of the Registrants against whom the Complainant filed allegations which they shared with the Complainant in their entirety. It is my opinion that the investigation was adequate. REASONABLENESS OF THE DISPOSITION
The College determined that the Deceased received appropriate care from each of the Registrants. The Inquiry Committee, in its response, writes: A careful review of his multiple medical problems in the last two or three months of his life, as outlined in the record and in the physicians' responses, identifies a number of serious conditions from which your brother was unlikely to recover. Many significant concerns were identified and were treated appropriately in accordance with the Level III protocol and your brother's wishes. Your insistence on Level IV care during the months of March and April is noted, however, your brother's personal wishes, in accordance with the DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
Representation Agreement, overruled your requests and directions. From an objective medical perspective, your brother's metastatic lung cancer, his general deterioration, his respiratory failure, and the overwhelming infections strongly suggested a palliative approach to care and was in your brother's best interest. Notwithstanding that widely held medical opinion, when your brother was no longer able to provide his own direction, thereby establishing your authority to direct his care, your wishes for Level IV intervention, including ICU treatment and the use of a respirator were complied with. The fact is that the Complainant and her sister who were so closely involved in monitoring the care the Deceased received do not agree with the actions of the Registrants. It is their belief that the Registrants did not take steps that might have prolonged the Deceased's life. That may be true but the Registrants, along with other professionals involved in the Deceased's care, understood that the Deceased had, while competent, indicated his desire for Code 3 intervention. He did not want extraordinary measures taken. He was a very ill man and had been advised that his stage 4 cancer was terminal. It was only when the Deceased was no longer competent that the family insisted on the provisions of the Representation Agreement which turned over the decision-making to the family. At that time, the Registrants allowed the family to take over the decision-making and agreed to transfer the Deceased to the Intensive Care Unit. Because the Complainant does not agree with the ultimate disposition of the College does not mean it is unreasonable. Having considered the Record in its entirety, I find it implausible that all of the professionals involved in the care of the Deceased could have misinterpreted his wishes; that is, that he did not want to be transferred to ICU at the end of his life. In my review of the Record, I find the disposition of the College is reasonable. This complaint centered around the end-of-life care provided to the Deceased by four Registrants. The Complainant accuses the Registrants of not providing appropriate care, appropriate medications or appropriate interventions which might have extended the life of the Deceased. The Registrants are also accused of ignoring the Representation Agreement in favour of their preference for a Code 3 status which would not have had the Deceased admitted to the Intensive Care Unit where his life could be prolonged. There is no disagreement among the four Registrants who are the subject of this review or any of the other specialists who attended the Deceased. His co-morbidities did not auger well for his recovery and any attempts to extend his life would only occur by use of life-supporting methods and absent those life-support methods, he would not be able to survive. All of these specialists understood and related that when the Deceased was competent to establish how he wanted his life to end, he elected Code 3 status; that is all care but no admittance to ICU. His sisters, however, insisted on intubation in ICU. The lack of clarity in the Representation Agreement and the family's insistence in the final analysis caused the physicians against whom these allegations of euthanasia are made to accept the family's wishes. The Complainant's position, in a nutshell, is stated clearly and emphatically: DECISION NO. 2010-HPA-0201(d);0202(d);0203(d);0204(d)
We know his medical history and condition; his ideosycchrasis to medications. He died of septic shock that could have been averted had he received the appropriate medical treatment in a timely manner. He did not die of cancer. CONCLUSION
I find the College's investigation adequate and its disposition of the complaint reasonable. Accordingly, the disposition of the Inquiry Committee is confirmed. In making these decisions I have considered all of the information and submissions whether or not specifically reiterated herein. "Marilyn Clark" Marilyn Clark, Panel Chair Health Professions Review Board June 29, 2012

Source: http://www.hprb.gov.bc.ca/decisions/2010-HPA-0201(d);2010-HPA-0202(d);2010-HPA-0203(d);2010-HPA-0204(d).pdf