Ernest Quintana was rushed to the hospital due to labored breathing. There, a doctor on a video screen told Quintana he didn't have long to live—leaving his family upset that the message hadn't come from an in-person caregiver, and highlighting potential ethical issues with telemedicine.
When the 78-year-old Quintana, who had an existing lung disease, was rushed to Kaiser Permanente Medical Center in Fremont, California, his family knew his health was failing. That particular hospital visit marked his third in 15 days.
While awaiting the results of a CT scan, Quintana's daughter Catherine and his wife went home to quickly shower, leaving Quintana's granddaughter, Annalisia Wilharm, with him.
According to Wilharm, a tall machine was rolled into Quintana's room with a video screen featuring live video of a doctor wearing a headset. A nurse accompanied the machine but she stayed silent, according to CNN. Wilharm began recording the doctor on her phone in order to relay the information on his prognosis to the rest of her family.
The doctor informed Quintana there was significant damage to his lungs. "Unfortunately, there's nothing we can treat very effectively," the doctor said. The doctor said Quintana could take morphine to relieve pain but that the drug could make it harder for Quintana to live.
When Wilharm mentioned home hospice care, the doctor said, "I don't know if he's going to get home."
Throughout the conversation, Quintana was having trouble hearing the doctor, as the machine was on the side of his deaf ear, according to Wilharm. As a result, Wilharm had to repeat what the doctor said to her grandfather.
Recalling the experience, Wilharm said, "I wanted to throw up. It felt like someone took the air out of me." She added, "I said, 'Do you want the morphine?' He looked at me like, 'What choice do I have?'"
Quintana died two days after the conversation with the doctor.
This interaction left Quintana's family upset about how the news was delivered. "It should have been a human," Catherine Quintana said. "It should've been a doctor who came up to his bedside." She added, "If you're coming to tell us normal news, that's fine, but if you're coming to tell us there's no lung left and we want to put you on a morphine drip until you die, it should be done by a human being and not a machine."
Wilharm said she assumed the visit was routine and was surprised by what the doctor said.
She added, "We knew that we were going to lose him. Our point is the delivery [of the news]. There was no compassion."
Michelle Gaskill-Hames, SVP for Kaiser Permanente in Alameda County, said officials "take this very seriously and have reached out to the family to discuss their concerns."
She explained, "Our physicians and nurses were in regular, in-person communication with the patient and family about his condition from the moment he entered our hospital." She added, "The evening video tele-visit was a follow-up to earlier physician visits—it did not replace previous conversations with patient and family members and was not used in the delivery of the initial diagnosis."
Gaskill-Hames added that Kaiser doesn't "support or encourage the use of technology to replace the personal interactions between our patients and their care teams." She also noted that Kaiser's practice is always to have a nurse or other doctor in the room during video visits.
Experts weigh in
Situations like Quintana's highlight some of the potential challenges providers can encounter when using telemedicine, according to John Banja, a medical ethicist at Emory University. In a case like Quintana's, telemedicine technology may not be able to communicate nuanced social cues, Banja said.
Barbara McAneny, president of the American Medical Association, said that delivering difficult news via telemedicine should be the "last choice" for a doctor. "We should all remember the power of touch—simple human contact—can communicate caring better than words," she said.
Meanwhile, Steven Pantilat, chief of the palliative medicine division at the University of California, San Francisco, said he was unfamiliar with the specific details in Quintana's case, but that telehealth technology has done great work for both patients and families, adding that video messages can be warm and intimate. He also noted that not every in-person discussion is empathetic and compassionate.
"No matter how well we deliver very difficult news, it's sad and it's hard to hear," he said (Jacobs, New York Times, 3/9; Har, Hawaii News Now/AP, 3/10; Andone/Moshtaghian, CNN, 3/10; Shannon, USA Today, 3/9).
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