Bowel Perforation

She was 85 years old with a bad heart and many chronic medical problems. Tonight, she had severe abdominal pain, and the CT scan showed a perforated bowel. Her future would include antibiotics and surgery. I was at a smaller hospital and spoke with my local surgeon. He was concerned that the patient was too sick to go to the operating room locally and she would need to be transferred to a bigger hospital. She would likely need ICU care afterward. Having abdominal surgery for a perforated bowel is a big deal, and with her baseline cardiopulmonary medical problems, it would likely be a rough road to recovery.

While she was in the ER, the patient started to deteriorate. She required more IV fluid to maintain her blood pressure. The problem was that her cardiopulmonary function was already poor. She already had fluid around her lungs, and let’s just say that her heart was not functioning like a 20-year-old’s heart. She also had some lab abnormalities that would need correction before the surgery. We started medication to help with her blood pressure before transferring her to another hospital.

There is generally a theoretically simple pathway to transfer from one hospital to another within the same health system. However, the patient’s daughter requested that the patient be transferred to a different hospital system because it was closer to the family and where she had previously been treated for her hip fracture earlier that year.

After all the phone calls and transfer arrangements were completed, I updated the patient and her daughter about everything. We discussed her code status, i.e., would she want us to perform CPR if her heart stopped? I stressed the gravity of the situation. As I sat across the patient’s bed from her daughter, the daughter reluctantly told me that her mother was “full code.”

They had recently had this conversation, and the look on the daughter’s face said it all. This was a daughter who clearly cared about her mother. She also had the sense to know that her mother was pretty ill at baseline and was now critically ill. She recognized that CPR in this situation would have a very low probability of a good outcome.

This was not the look of a daughter who wanted her mother to die; there was no malice, only realism. As tears welled up in her eyes, I told her I knew exactly what she was thinking. She was doing what her mother wished, despite knowing that it might not be the best thing for her mother in the long run.

The patient was loaded into an ambulance and transferred to the other hospital shortly thereafter. As the daughter left the ER, she turned and asked me, “Will she survive the ambulance ride?” “Yes, I think so. But after that, I don’t know.”