Allegation:
The defendant family medicine physician failed to recognize that stopping Plavix® prior to a colonoscopy could result in cardiac arrest and death.
The Case:
A 60 YOF (4’10”, 174 lbs.) presented to the ED complaining of chest pressure that was “like a truck standing on her chest,” and was diaphoretic. The patient had an extensive medical history including abdominal hysterectomy, herniated lumbar disc L-4 and L-5, spinal fusion, scoliosis secondary to polio, chronic right foot ulcer and osteomyelitis, UTIs, urinary incontinence, PID, sleep apnea, GERD with esophageal ulcer, asthma, COPD, HTN, and DM. Her medications included Singulair®, Flonase®, Advair Diskus®, bisoprolol-HCTZ, Prilosec®, Amaryl®, Zetia®, Reglan®, Antara®, ASA, Proventil®, Lyrica®, Skelaxin®, and tramadol. She did not smoke or drink alcohol.
The ED staff stabilized the patient and consulted cardiology. A chest x-ray was stable, without evidence of heart failure. LDH and CPK were elevated and the ECG was abnormal. A diagnosis of an acute MI was made. The patient had an angioplasty in the cardiac catheterization lab, and a drug-eluding stent was placed by interventional cardiology.
The patient was monitored in the CCU where she experienced mild CHF that responded to diuretics. Cardiology prescribed Plavix and ASA daily. Her cardiac status, including ejection fraction, steadily improved; she was discharged in stable condition three days after arrival at the ED. Her new additional medications included Plavix, ASA, Zocor®, Nitrostat®, and Coreg®.
Approximately three weeks post-discharge, the defendant family medicine physician referred the patient to a urologist for complaints of urinary urgency and worsening incontinence, requiring protective pads. The urologist recommended additional evaluation with a flexible cystoscopy in one month.
Four days following the urology visit, and almost one month after her hospitalization and cardiac procedure, the patient had complaints of diarrhea after being prescribed Zestril® and Lopressor®. She contacted the defendant family medicine physician, and OTC Kaopectate® was suggested as a treatment. An additional four days later, the patient saw the defendant family medicine physician with continued complaints of diarrhea. Her glucose was elevated to 210 (65-99 mg/dl). Other labs were normal, and an abdominal x-ray showed large amounts of stool and fecal impaction. Mineral enemas were prescribed two hours apart followed by a Fleets enema.
The patient returned 10 days later to the defendant family medicine physician with worsening diarrhea and weakness. Her glucose was 125 mg/dl (65-99) and Hgb A1C was 7.6 (<5.7). A stool sample was positive for toxigenic clostridium difficile. The defendant diagnosed her with LLQ pain, diarrhea, diverticulitis versus other, post hospitalization. The defendant prescribed Flagyl® and Cipro®, and told the patient to return in one week.
The patient returned as directed for a recheck. Diverticulitis was resolved and she had returned to a regular diet while finishing the antibiotics. The defendant referred her to a gastroenterologist for a colonoscopy, and the procedure was scheduled for seven weeks later. The referral noted she was taking Plavix.
The patient returned to the defendant family medicine physician one month later with a complaint of diarrhea for three to four days. She believed the diarrhea was related to her heart medications, and wanted to stop taking Plavix. The defendant documented the discussion of not stopping Plavix due to potential increased risk of MI following a stent. Further documentation stated she would stop Plavix 10 days prior to the colonoscopy in three weeks. Lomotil was prescribed for symptom management.
Nine days after stopping Plavix, the patient arrived by ambulance to the ED with complaints of severe chest pain, onset during rest, with radiation to the LUE and not worsened or relieved by anything. She had difficulty breathing, nausea, diaphoresis, and abnormal ECG. The ED staff placed a central line, intubated the patient, and inserted a pacemaker, at which time the patient went into cardiac arrest. Staff initiated ACLS protocol and 30 minutes later, pronounced the patient dead. The staff did not perform an autopsy, and the cause of death was acute MI.
Experts for the plaintiff stated the patient should have been on Plavix for at least one year post-stenting, and that interruption or termination of the Plavix therapy increased the risk of an acute MI and death. One plaintiff expert also stated the risk of bleeding from a diagnostic colonoscopy was outweighed by the risk of harm from stopping the Plavix. The expert’s belief was that, more likely than not, the patient would still be alive had the anti-platelet therapy continued.
Defense expert opinions ranged from supportive to critical. Defense experts had questions about the need for a pacemaker and intubation, and found the ECG reading was actually ventricular tachycardia, requiring immediate shocking and antiarrhythmic agents.
Verdict:
The case was settled upon the request of the defendant family medicine physician. When faced with a patient making demands that are inconsistent with medical professional decision-making, consider the use of a refusal of treatment form.
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