Lara Vogel, M.D.
Resident, Harvard Affiliated Emergency Medicine Residency
MGH/BWH,
PGY 4
08/28/2019
Conversations surrounding code status and informed consent
are a huge practicality of my job, and one I think I will always feel less
prepared for than I should be. In the ER, I frequently give bad news, explain
complex medical conditions, try to parse the high uncertainty of early
diagnosis and ask for consent for treatment in only a few minutes. In another
language, across a cultural barrier, with interpreters, there is of course
additional layers of complexity. But even in my native language, these conversations
are riddled with small misunderstandings and subtle nuance that make them
difficult to leave feeling certain that we all share the same understanding of
the patient’s condition and values and what I hope to treat and how.
In Kigali, I was a teacher—I could not speak to many of the
patients without interpretation (Kinyarwanda was the strongly dominant language
for this patient population), and I appropriately did not independently manage
their care without residents and attendings involved in my decision making.
However, even with interpreters I trusted and with time to talk to patients as
my administrative duties were lessened, my chance for truly informed consent
seemed slight given the vast distance of culture, language, and medical
training between me and my patients. As
a result, I often left these conversations to the residents directly caring for
patients, intervening only when I thought medical care was not being discussed
at all. However, I was not prepared for the additional layer of consent
conversations that had to be done by the physicians prior to the patients and
their families. In a relatively resource-poor setting, there was often no
conversation to be had with patients and their families. When we ran out of
ventilators, when radiologists would not read a study, when the lab ran out of
a certain test’s supplies, when patients could not afford central line or other
equipment, we did everything else we could. I personally had not prepared for
the brief but important preliminary discussion that had to be had among
physicians regarding the resources available at any given time- resources were
a fluid and changing thing but when they were gone, there was not always an
alternative to discuss with a patient.