Failure to diagnose fecal impaction

by Laura Hale Brockway, ELS, Vice President, Marketing‍

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Presentation

On February 26, a 67-year-old man was admitted to the hospital by ambulance for shortness of breath. He had wheezing and respiratory distress with a heart rate of 120 bpm and blood pressure of 217/138 mm Hg. 

The patient had a history of COPD, hepatitis C, hypertension, and IV drug abuse with methadone treatment. The patient had been hospitalized several times for advanced COPD, including a prolonged stay with mechanical ventilation and tracheostomy for Pseudomonas pneumonia. Three weeks before his latest admission, he had been hospitalized with acute exacerbation of COPD. 

Physician action

Hospitalist A treated the patient with bronchodilators and steroids. His condition improved, but he was later transferred to the ICU for BiPAP. The patient was intubated on March 1. 

Though a CT scan showed no evidence of pulmonary embolism, Hospitalist A was concerned that the patient had aspirated and developed pneumonia. The patient was treated with antibiotics and kept sedated with fentanyl and propofol while he was ventilated. 

On March 7, Hospitalist B noted that an ultrasound of the right arm demonstrated subacute/chronic right subclavian and basilic vein occlusive thrombus. The ultrasound technician noted track marks on the patient’s arm due to IV drug use. The results of a d-dimer test were normal.

According to the medical record, the results of abdominal exams conducted during this period were normal, though the patient had not had a bowel movement in six days. 

Hospitalist B examined the patient on March 8. He described the patient’s abdomen as distended with hypoactive bowel sounds, yet also noted the abdomen was soft and non-tender. An advanced practice provider (APP) working with Hospitalist B ordered docusate. 

At 3 p.m. that day, a nurse notified the APP of the patient’s positive sepsis screen. The APP ordered blood cultures and prescribed piperacillin/tazobactam and vancomycin. Hospitalist B noted at 6:46 p.m. that the patient’s abdomen was soft and nontender, and that the patient most likely had fecal impaction/ileus. Hospitalist B ordered an enema. The patient developed lactic acidosis, worsening hypotension, and an elevated white blood cell count. He was given normal saline and vasopressors throughout the night.

Hospitalist C — who was on call for Hospitalist B — was asked to see the patient at 2:50 a.m. The patient had a severely distended abdomen and Hospitalist C suspected a perforated bowel.  The patient’s tube feedings were stopped, and a nasogastric tube suctioned one liter of stomach contents. The patient’s condition declined, and he went into cardiac arrest. CPR was started, but his family asked for it to be terminated. The patient died. 

Hospitalist C noted in the patient’s medical record that the cause of death was “septic shock due to bacteremia likely from perforated bowel.” There was no autopsy performed. The cause of death was listed as cardiac arrest due to severe sepsis with septic shock.

Allegations

A lawsuit was filed against the hospital and Hospitalists A and B, alleging that the patient developed constipation and ileus that went untreated for six days. This led to the bowel perforation that caused the patient’s death. 

Legal implications

The plaintiff’s critical care expert claimed that Hospitalists A and B failed to meet the standard of care because they did not monitor the patient’s bowel activity, perform abdominal exams, or timely obtain imaging when it was discovered that the patient had not had bowel movements. According to this expert, the patient’s history of opiate use put him at risk for severe constipation, fecal impaction, and bowel perforation, which should have led to greater vigilance from the defendants. 

Critical care experts who reviewed this case for the defense questioned whether the patient’s death could be attributed to the fecal impaction. One critical care specialist suspected the patient’s death was more likely caused by respiratory failure and septic shock due to end-stage COPD and viral hepatitis-associated cirrhosis. 

Another critical care specialist noted that the patient had been treated for constipation as an outpatient secondary to IV drug abuse and methadone treatment. Fecal impactions in that setting and in the ICU are common. Yet colonic perforations from impactions are rare and can only be diagnosed by specific findings during surgery or at autopsy. “From the evidence available in the hospital chart, the idea that this patient had colonic perforation was an ill-considered speculation by [Hospitalist C] with no objective findings to support it.” 

Despite these causation arguments, the defense was compromised because there was no evidence in the medical record that the patient’s absence of bowel movements had been addressed. The nurses documented normal bowel sounds and no issues with bowel movements. Nursing notes on February 27, March 1, 3, 5, and 6 indicated “stool normal.” Only one bowel movement was recorded on February 27. On March 7, a nursing entry noted “passing flatus.” One expert stated that the physicians may have been misled by these multiple “stool normal” entries.

Additionally, Hospitalist B stated that when she sees a patient, she always asks the nurses if the patient had a bowel movement. However, none of these discussions were documented in the medical record for this patient. 

Disposition

This case was settled on behalf of Hospitalists A and B. The hospital also settled their case. 

Risk management considerations

In this case, communication among those caring for the patient was less than ideal. Important information about the patient’s lack of bowel movements was not accurately relayed to Hospitalist A or B. A disconnect also occurred because there were standing orders in the patient’s medical record for stool softening and for help with bowel movements, but the nurses did not act upon these orders. 

Documentation was also an important factor in this case. Conversations between the nurses and Hospitalist B about the patient’s bowel movements were not documented in the record. The defense was concerned that the failure to document these discussions could be interpreted as Hospitalist B failing to check on the patient’s bowel movements. 

Physicians are encouraged to document their conversations with other caregivers, as this can help maintain clear communication between providers and consistent care for the patient. This is especially true if conversations relate to a review of systems, standing orders, or new symptoms.