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SUMMER 2017
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In the first case, it would seem apparent that intubation of
this patient would be inappropriate as he states “he is DNR.”
However, he is a relatively young man who would more likely
than not have his life saved with temporary invasive ventilation.
He is noted to be fully alert and oriented, but how much does
he really understand about being DNR? His family, unaware
of his wishes, caught off guard and unable to speak with
their brother, understandably requests “everything be done.”
Intubation would appear to be a violation of the patient’s right
to self-determination. However, this violation of his autonomy
is certainly influenced by the opinion of the physician who feels
that intubation would be only a temporary sacrifice and would
be lifesaving with only temporary discomfort for the patient.
How do we handle the second case? An advanced directive
is clearly noted on the nursing home transfer sheet and the
health care proxy cannot be reached. However, given the
patient’s condition and horrific x-ray, intubation will prolong
life, but will likely result in no clinical improvement and, in the
opinion of many, will only prolong suffering. Is there a role for
paternalism in this case? Can the ED staff act with paternalism
here and “do no harm” by not intubating and allowing a natural
death? Is it appropriate to violate the patient’s right to life under
the principles of beneficence (first do no harm)?
Epilogue:
Mr. B is successfully extubated after 36 hours of ventilator
support. He vividly recalls the events in the ED and remains
angry at being intubated against his will even though he is alive.
He does not feel that intubation was necessary to save his life.
A family meeting is held with his sister who is appointed his
health care proxy. The patient clarifies his wishes stating that he
is no longer DNR, and would allow intubation, but would not
want prolonged artificial life support if there was no hope he
could live without a machine. Surprisingly, he does not express
gratitude towards the ED doctor.
Mrs. G is intubated and sent to the MICU. Her health care
proxy is reached the next day and after discussion regarding the
patient’s prognosis, the decision is made to transfer the patient
to the hospice unit the following day. Family gathers and the
ventilator is stopped the next day. She peacefully dies two days
later in the presence of family. The family is grateful they had
the time to be with the patient when she dies.
“THESE CASES ILLUSTRATE
THE CONFLICTS BETWEEN
PATIENTS’ RIGHTS ... AND
DOCTOR’S DECISIONS.”
Routine ExamResults in
Far-From-Routine
Brain Surgery
By Steven Clark
CASE STUDY
A routine eye exam may have
saved Oina Aquino’s life.
It was during Holy Week in April that
the 33-year-old mother of two had
gone to visit an eye doctor as part of the
physical required for a job as a home
health aide. During the eye exam, it soon
became apparent to the optometrist
that something was wrong. While Oina
had lived with blurred vision for about
15 years – because, she thought, she
was no longer wearing glasses – the
doctor became alarmed by the abnormal
pressure she discovered in the back of
Oina’s eyes. She immediately put her into
a cab, directing the driver to take her to
the emergency department at SBH and
handing the Spanish-speaking woman
a note telling the triage nurse that she
needed to be seen immediately.
Within minutes of her arrival at the
hospital, she was taken for an MRI. The
news soon got worse when the picture
revealed a large mass on her brain. Shell
shocked, and repeating to her older
sister, LoAna, “I feel fine, I feel fine,”
she was transferred to the ICU, where
she met neurosurgeon Dr. William
Wirchansky the next morning.
“I explained to her and her family that
this was something we’d have to remove
right away,” says Dr. Wirchansky. “I told
them this would be complicated surgery
because of the location of the tumor [on
the left side of the brain, abutting the
corpus callosum, the white matter that
connects the brain’s two hemispheres],
and there was a risk from the surgery of
weakness and other neurological deficits,
even paralysis.”
The diagnosis and the need for risky
surgery hit Oina hard. Although she had
recently been experiencing increased
pressure on her head – “it felt like a
vise” – it was all happening too fast. She
needed time to think. So, she left the
hospital that day to consider her options,
returning to the home her sister and
brother-in-law had generously opened
to Oina and her children a year earlier
when they had migrated from the
Dominican Republic.
Two weeks later, on April 25th, she
returned to SBH, for brain surgery. The
next morning, she was prepped for an
operation that Dr. Wirchansky told the
family could last for six or more hours.
Using a sophisticated device called
stereotactic image guidance, which
enabled him to visualize the anatomy
of Oina’s brain during the surgery and
precisely track the location of their
surgical instruments in relation to the
anatomy, Dr. Wirchansky made a track
through her brain, right in front of the
motor cortex. This is the region of the
cerebral cortex involved in the planning,
control and execution of voluntary
movements. With the navigation system,
accompanied by a device called CUSA
(cavitronic ultrasonic surgical aspirator)
and an operating microscope that
provides for enhanced magnification,
the neurosurgeon was able to avoid
any collateral damage as he entered
the ventricles of the brain and started
resecting the tumor. The ultrasound
waves emitted by CUSA emulsified
the target tissues, causing the cells to
disassociate from one another while
the device irrigated the area with sterile
saline. During the approximately eight-
hour-long surgery, he was able to remove
virtually the entire mass.
Pathology found the four to five
centimeter tumor – “the size of a small
orange,” says Dr. Wirchansky – to be
a ganglioglioma. This is a rare tumor,
representing about one percent of all
brain tumors, that is almost always seen
in a pediatric population (which is when
it most likely began to invade Oina’s
brain). Although a ganglioglioma tends
to be benign – Oina’s tumor was revealed
to be a WHO grade 1 – if left untreated
it can cause worsening symptoms (such
as seizures and other neurological
problems, as well as permanent vision
damage), and lead to death.
Oina woke up several hours after the
surgery without any neurological affects,
and with her vision no longer blurred.
Weeks later, during a routine checkup
with Dr. Wirchansky, her phone rang
with a text message. She could be seen
casually glancing at the words that came
across the tiny screen of her cell phone –
something she would have been unable
to do before the surgery. Her plan is to
begin working with elderly people in the
very near future.
SBH patient Oina Aquino (l.) with Dr. Wirchansky (r.)
