ORGAN FAILURE

SUMMARY: Acute failure of previously healthy internal organs is often fully reversible following prompt diagnosis and appropriate management. Acute-on-chronic failure may trigger flawed medical malpractice. Actions because relatively asymptomatic functioning may rapidly progress to life-threatening severe illness. Certain features of misdiagnosis predict probable viability of medical malpractice litigation.

An acute disease process can overwhelm an organ`s ability to function, yet leave little or no residual damage once that disease has healed.  A dramatic example is the short-lived failure of a number of organ systems in newborn infants who have suffered severe asphyxia (profound blood- and oxygen-deprivation) during labour and delivery.  Even if permanent neurological damage results, recovery of internal organ functions is usually complete in such circumstances. 

A number of body organs have reserve capacity.  While that capacity is being reduced by a chronic disease process, the organ may continue to function relatively normally with little in the way of symptoms. Conversely, when that spare capacity is exhausted, minimal further progression of disease process can cause dramatic and progressive symptomatic and functional consequences. 

Acute-on-chronic failure may trigger flawed medical malpractice Actions because relatively asymptomatic functioning may rapidly progress to life-threatening severe illness.

Kidney

Until three-quarters of the tissue is destroyed, the kidneys continue to eliminate waste material and balance body fluids and salts fairly efficiently, unless the body is under unusual physiological stress. 

The definitive test for kidney function is Glomerular Filtration Rate (GFR), a value calculated from measurements of the hourly amount of creatinine removed from the body in the urine and the concentration of creatinine in the blood (serum).  Serum creatinine alone, and to a lesser extent blood urea, detects impaired kidney function in many circumstances, but acute renal failure can be present with relatively normal blood concentration of these two waste products. 

Liver

Replacement of much of the liver by scar tissue, as in cirrhosis, does not necessarily cause adverse consequences on the capacity of the liver to detoxify the body and generate a wide range of chemicals required for health. 

As the organ reserves dwindle, however, anorexia, weight loss, malaise and debilitation may appear or, while the patient is feeling fairly well and energetic, complications may supervene - fluid in the belly (ascites), internal bleeding, spontaneous peritonitis, or impaired consciousness and brain functioning (encephalopathy). 

Lungs

In the early stages of destruction of lung tissue, breathing capacity and exercise tolerance may be compromised only under physiologically demanding conditions. 

Practical Pointer

Acute respiratory failure is characterised by: 

  • breathlessness

  • tachypnea (rapid breathing)

  • impaired oxygenation of the blood

  • carbon dioxide accumulation in the blood

Acute on chronic respiratory failure is seen most commonly in emphysema, the commonest cause of which is cigarette smoking. 

As in failure of other organs, compromised immunity complicates respiratory failure and pneumonia or sepsis may be the Proximate Cause of death. 

However, the breathlessness, perhaps with wheezing and cough, of acute respiratory failure in the elderly is most commonly caused by cardiac (heart) failure 5 [Full Text] and may be misattributed to lung conditions such as infections or new-onset bronchial asthma.  

Heart

The heart may pump adequately for sedentary life, and even during moderate exercise, despite fairly extensive damage from a variety of disease processes.

Chronic Heart Failure (CHF) is common, being present in 1 in 8 general practice patients over the age of 60.  5 [Full Text]

Medicolegal Implications

Medical malpractice Actions that arise from death in cigarette-induced respiratory failure and in alcoholic cirrhosis illustrate the "denial" that is present in not only the sufferer, but also his family.  A frequently recurring theme in these cases is the belief that the relative progressed rapidly from independent living to death in the Intensive Care Unit because of substandard medical management or nursing care or both.  More often than not, this does not prove to be substantiated on detailed review of the clinical records. 

Certain features of misdiagnosis predict probable viability of medical malpractice litigation.

Emergency Department misdiagnosis between the lung and heart causes of acute respiratory failure usually reflects substandard clinical assessment, commonly because chest radiographs or ElectroCardioGram (ECG) are not ordered or are misinterpreted.  Such diagnostic error often proves to be a viable Cause of medical malpractice Action, because the management of the two types is radically different.  In a French emergency department series, an inappropriate treatment occurred in a third of  patients, and such misdiagnosis was associated with double the usual mortality rate. 5 [Full Text]

Most episodes of Acute Renal Failure (ARF) in hospitalised patients  are iatrogenic, commonly as a result of medications that are potentially damaging to the kidneys being administered patients whose underlying medical conditions make them susceptible to such injury - dehydration, diabetes mellitus, Chronic Heart Failure (CHF), Chronic Renal Failure (CRF), the elderly.2 [Full Text] 3 [Full Text]

For cases arising out of liver failure, medical malpractice Actions most commonly take the form of a complaint that the attending physician did not refer the deceased in timely fashion for specialist assessment for liver transplant.  Hepatologists frequently complain of such late referrals and some will provide Plaintiff expert opinion on both Standard of Care and Causation. 

Practical Pointer

Common potentially viable Causes of Action: 

  • misdiagnosed respiratory failure - missed radiographs or ECG

  • acute renal failure - drugs when vulnerable

  • liver failure - late referral for transplant

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