Understanding when a patient needs to be on medication is one of the most important judgment calls a physician can make. But the decision isn’t always so clear, and the need for medication must be weighed against the side effects and potential hazards of the treatment as well. This month we look at a case where a physician made a judgment call and ended up being judged harshly for it.
The patient, Mr M, a 72-year old Caucasian male, was brought into the emergency department of the hospital one evening in early June. His wife told the triage nurse that he had been complaining of shortness of breath for the past few hours and had started sweating profusely; she became worried and insisted that he go to the hospital.
Mr M was a large, burly man, at least 30-40 pounds overweight. He suffered from hypertension, for which he had been taking medication for many years. A former smoker, Mr M had managed to kick the habit a few years ago. The patient was a retired sanitation worker, but now led a mostly sedentary lifestyle.
The cardiologist treating Mr M at the hospital was Dr H, 48. After several days of tests, Dr H diagnosed the patient with congestive heart failure and atrial fibrillation and prescribed him a blood thinner. Mr M was later discharged with an appointment to follow-up with Dr H at his office to discuss managing his atrial fibrillation.
A week later, Mr M went to see the cardiologist in his office for the first time. After an examination, Dr H concluded that Mr M appeared to be doing well. The physician decided to keep the patient on the warfarin at this time and reevaluate him in another 2 months.
Two months later, in August, Mr M returned for his follow-up appointment. Dr H was pleased with the patient’s progress. In the previous 2 months, Mr M had made a clear effort to eat healthier and to try to walk more to get some exercise. After a brief examination and a discussion with the patient, Dr H decided to take him off the warfarin, concluding that the patient was not at an increased risk of blood clots.
Over the next year and a half, Dr H continued to monitor the patient every 4 to 6 months. Nothing out of the ordinary happened during that time, and the physician continued to be pleased by the motivation he was seeing from the patient, who now had dropped close to 20 pounds and was making an effort to walk for 30 minutes on most days.
One winter afternoon, however, Mr M was watching TV when he began feeling strange. He called his wife in and described how his left side suddenly felt weak and that he wasn’t sure he could walk. His wife noted that the left side of her husband’s face was drooping strangely, and his speech sounded abnormal. She quickly called an ambulance and he was rushed to the emergency department.
An electrocardiogram revealed that the patient’s heart was in atrial fibrillation. He was quickly diagnosed as having an evolving stroke from a clot in his brain. Because he had been brought to the emergency department so quickly, he was within the window of time to be given clot-busting medication. However, despite the rapid treatment, Mr M was left with an inability to use his left side and was confined to a wheelchair. He requires assistance with most activities of daily living.
At the advice of friends, Mrs M, the patient’s wife, sought the counsel of a plaintiff’s attorney. Dr H was notified that he was being sued for negligence in discontinuing the patient’s warfarin. When he met with the attorney assigned from his malpractice insurance, the attorney asked why he had taken the patient off the blood thinner.
“It was a judgment call,” said the doctor. “He was doing well. He was making lifestyle changes. I felt under the circumstances taking him off the medication was the right choice at the time.”
The case proceeded towards trial.
During the discovery phase, both parties were required to turn over all notes, records, and other material, and the parties were all subject to depositions. Expert physicians were hired on both sides, and their depositions were taken as well. Mr M’s expert was prepared to testify at trial that in his opinion Dr H was negligent in discontinuing the plaintiff’s warfarin. The expert believed that Mr M was at a very high risk for developing clots from his atrial fibrillation if not on anticoagulation medication. The expert was expected to testify that Mr M’s stroke would not have occurred were he on medication.
Dr H’s expert was prepared to testify that taking Mr M off the warfarin was a reasonable judgment call and not negligent in this situation. This expert was expected to testify that in her opinion Mr M was not at a significantly increased risk for developing blood clots.
After the discovery phase, the parties were able to settle the case out of court for an amount within the physician’s medical malpractice limits. Although he believed the case could be argued, Dr H’s attorney encouraged him to settle because of the very high costs involved with medical malpractice cases, and the uncertainty of the outcome when a jury is involved.
According to the CDC, atrial fibrillation increases a person’s risk for stroke by 4 to 5 times compared with stroke risk for people who do not have the condition, and atrial fibrillation causes 15%-20% of ischemic strokes. Strokes caused by atrial fibrillation tend to be more severe than strokes from other causes.
Dr H made a judgment call to take the patient off warfarin, but he did not note in the patient’s record his justification or thought process in doing so. Had he done this, he would have been in a stronger position at trial.