Why why why

[radslooking]

I was standing there looking down at an end stage dementia patient who just recieved surgery and had been changed from DNR/DNI to full code by a family member. sigh.....

Sometimes i wonder if patient's family members truly have the patient's best interests at heart or are feeding their own insecurities, and or reluctant to make a decision they could get criticized for. Sometimes I wonder if it would be better if we were allowed to step in and say enough is enough.

as for the surgery, it was for bowel gangrene, so I don't necessarily fault that I guess, since that's a particularly undesirable way to die. however, you could consider dialing up the morphine in that case as well.

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[cpants]

You know, believe it or not, docs can write DNR's without family approval. If a patient is terminal, with no chance of recovery, CPR is actually not medically indicated.

Of course, it is best to get the family on the same page with this. They likely don't understand the situation or have some guilt or emotional issues barring their actions. No one wants to feel like they are pulling the trigger on grandma. Time for the physician to gently say "there is no chance of any recovery. I would not feel comfortable doing CPR to prolong the suffering of this patient."

Another issue is that patients' families have no idea what CPR is actually like. TV CPR usually involves a few chest pumps and maybe a shock by a hot intern, and then the patient wakes up 75% of the time. Description of what it's actually like--ribs breaking, tubes down the throat, and a ~5% chance of "success" which will likely mean the patient lives on machines for a few more weeks--might help the family realize their loved one would rather die peacefully and comfortably on pain meds in a hospice or at home.

 

[docB]

Description of what it's actually like--ribs breaking, tubes down the throat, and a ~5% chance of "success" which will likely mean the patient lives on machines for a few more weeks--might help the family realize their loved one would rather die peacefully and comfortably on pain meds in a hospice or at home.

I couldn't agree more. Especially with your expression of "success." The main reason that these atrocities continue is the medical malpractice crisis. It's absolutely ethical and medically indicated to tell a family "There is so little chance of recovery that more interventions are not indicated and I won't do them." But we all live in fear of the summons and the lawyers doing the "cha-ching" dance because some relative wants to work out their unresolved childhood issues in a courtroom.

 

[listeriaismfb]

Families don't get it, that's why. They think that by making their loved one DNR/I that they're being disloyal or worse. They also think that by not making someone DNR/I, that they're not making a choice. Wrong!

The DNR/I issue, if there is no chance of a *meaningful recovery* it is a moral imperative to let your loved one go. Period.

There's a million ways to say it, everybody dies. You can die at home surrounded by loved ones or you can die in the hospital after 4 weeks on the vent with a giant decub on your butt.

 

[radslooking]

It just seems i run into a lot of folks who are fixated on the fact that grandma was able to talk with the kids last year, and now she can't, but they'd like her to get back to that. Or, man, he was just riding his 3 wheeler a few weeks ago even though he has peritoneal carcinomatosis all over his abdomen. I mean, its a denial process that needs to be helped along sometimes.

I think what I am going to start saying is something like this: "in cases where there is little chance for meaningful recovery we typically do not perform CPR which can be very traumatic and painful, and likely will not help. So that's what I would recommend." It's just not useful to say "what would you like us to do in event his heart stops or he stops breathing" because everyone will say, "hell yes! Just shock him back to life! keep him alive!".

Unfortunately, how you frame the question I think makes a huge difference. They should start teaching people how to address this issue.

 

[PeepshowJohnny]

I agree, but I've seen cases where even doing the speech the right way you still get a son or brother or husband who threatens physical harm if everything isn't done.

The problem isn't just us, it's that society has lost our cultural ability to cope with death. Talk to people old enough and they'll tell you about how their previously healthy family members died in their beds from pneumonia. It's tragic, but they thrived on. Now we've got people begging us to bring back people who really "died" years ago.

 

[docB]

Cool comic about the topic at hand:
(link takes you to archive, go to 7/27/08 comic on pulldown, sorry, couldn't link directly)
http://www.grimmy.com/archives.php?archive=MGG

Seriously tho, ask anyone who works in EMS, ICU or the ED if they would want to be a full code even if they had a lot of health problems and/or a poor chance at recovery. They'll practically all say no.

That means we're treating our patients differently than we would ourselves or our family members. Doesn't that, by definition, make what we do now (coding everyone based on family preference and misperceptions rather than medical history) unethical?

 

[radslooking]

IThe problem isn't just us, it's that society has lost our cultural ability to cope with death.

I agree with this, and it truly boggles my mind. Why is death terrible? To me it seems like a much more palatable alternative than hobbling along in pain or poor health until your death. It seems so plainly obvious to me, I just don't understand why our culture is so different. Maybe I'm a cold hearted bastard.

 

[NonTradMed]

I agree with this, and it truly boggles my mind. Why is death terrible? To me it seems like a much more palatable alternative than hobbling along in pain or poor health until your death. It seems so plainly obvious to me, I just don't understand why our culture is so different. Maybe I'm a cold hearted bastard.

It's because we don't see as much death anymore. I remember a doctor who mentioned a patient of his whose child died recently. He commented how "no parent should have to bury their own child"....only thing was, 150 years ago, most parents *did* bury at least one or two of their children. And before that, death was such a commonality of life that people accepted as inevitable. But we are so rarely touched by death and the media feeds us 'medical miracles' where a 20 year coma patient raise up, where patients on TV shows magically recover from the most obscure/severe diseases, people think that's how real life operates. If the last 30 years was about expanding life, I think the next 30 years will be about maintaining *quality* of life. We need to stress hospice care over intensive care, would do wonders on pocket books and on patients.

 

[PeepshowJohnny]

We need to stress hospice care over intensive care, would do wonders on pocket books and on patients.

(The rest of your post is excellent but I only have a response for this small part)

You know what's amazing though? I did a rotation with a palliative medicine guy. You know why I a lot of people initially refuse hospice care? (Especially old men).

The think it costs too much.

And it's understandable to think why. "My God! The nurse is coming out to the house to check up on me!? This is extravagent!"

They don't understand that if the pain gets too much at home, and they call an ambulance to admit them to the hospital (or maybe some family member gets antsy) the cost is so, so, so much more.

There really needs to be better education on this stuff.

 

[Tired]

My living will has an anti-DNR.

Don't assume every gorked gomer wants the tube pulled.

 

[ZincFingers]

My living will has an anti-DNR.

Don't assume every gorked gomer wants the tube pulled.

Help yourself. When it's my turn to be a vegetable who needs someone to roll him over every 4 hours to prevent bedsores... pull the plug with both hands.

 

[GassiusClay]

It's interesting to hear from physicians who have probably seen so much cr@p end of life issues wanting anti-DNRs. I understand if you are young that you would want some measures tried before pulling the plug, but I would have something built into the will about having a limit on being a gorked gomer.

These gomers we speak of cost medicine a lot. Putting cost aside, I think most are allowed to "physically" live because the means exists. I highly doubt anybody concedes to the idea of a God taking one's life. In a world about cosmetics and atheism, I assume most fear death rather than learning to expect it like those third world peons do.

Is it true that a person costs more in their last 6 months of life compared to the rest?

 

[docB]

It's interesting to hear from physicians who have probably seen so much cr@p end of life issues wanting anti-DNRs. I understand if you are young that you would want some measures tried before pulling the plug, but I would have something built into the will about having a limit on being a gorked gomer.

To clarify that was one physician's viewpoint. It is more common to hear from people involved in end of life care that we wouldn't want such interventions. That is because we see how invasive, painful and pointless those interventions are.

 

[Tired]

To clarify that was one physician's viewpoint. It is more common to hear from people involved in end of life care that we wouldn't want such interventions. That is because we see how invasive, painful and pointless those interventions are.

Then there's the flip-side, which we never ever talk about:

People with DNRs get substandard care. They have all significant interventions withheld, not just "extraordinary measures". When we round on them, we don't even bother to walk in their rooms most mornings. When they come into the ER, even for unrelated issues, we dose them up with narcs and walk away.

A DNR means "We Won't Treat You", pure and simple.

If everyone else is comfortable with this, great. Not me. I've seen too many soldiers and Marines walk out of the hospital after "devastating" head injuries. And I've seen too many wheeled out in body bags because the plug was pulled too early.

 

[docB]

Then there's the flip-side, which we never ever talk about:

People with DNRs get substandard care. They have all significant interventions withheld, not just "extraordinary measures". When we round on them, we don't even bother to walk in their rooms most mornings. When they come into the ER, even for unrelated issues, we dose them up with narcs and walk away.

A DNR means "We Won't Treat You", pure and simple.

If everyone else is comfortable with this, great. Not me. I've seen too many soldiers and Marines walk out of the hospital after "devastating" head injuries. And I've seen too many wheeled out in body bags because the plug was pulled too early.

That's a good point but when any doc does that they are practicing incorrectly. DNR does not mean do not treat. Patients who do not want to be intubated or coded can and should still get whatever treatment is appropriate outside of those limitations. DNR is there to save the patient from unreasonable pain, not to save the physician from work.

It's also important to note that most of us aren't talking about the young trauma victim here. We're talking about the 80+ yo demented nursing home microbiology experiment. Don't let me become a petri dish.

 

[Mozart45]

Then there's the flip-side, which we never ever talk about:

People with DNRs get substandard care. They have all significant interventions withheld, not just "extraordinary measures". When we round on them, we don't even bother to walk in their rooms most mornings. When they come into the ER, even for unrelated issues, we dose them up with narcs and walk away.

A DNR means "We Won't Treat You", pure and simple.

If everyone else is comfortable with this, great. Not me. I've seen too many soldiers and Marines walk out of the hospital after "devastating" head injuries. And I've seen too many wheeled out in body bags because the plug was pulled too early.

Wow, I never thought of a dnr as we won't treat you. At the hospital I work at whenever we have the do you want to make your loved one a dnr/end of life issues the physicians specifically say to the family members that a do not resuccitate order does not mean we will quite caring for your loved one. And then continue to explain that we continue to keep their loved one comfortable, etc. Not rounding on a patient that is a dnr seems unacceptable and poor quality of care.

 

[PeepshowJohnny]

Then there's the flip-side, which we never ever talk about:

People with DNRs get substandard care. They have all significant interventions withheld, not just "extraordinary measures". When we round on them, we don't even bother to walk in their rooms most mornings. When they come into the ER, even for unrelated issues, we dose them up with narcs and walk away.

A DNR means "We Won't Treat You", pure and simple.

If everyone else is comfortable with this, great. Not me. I've seen too many soldiers and Marines walk out of the hospital after "devastating" head injuries. And I've seen too many wheeled out in body bags because the plug was pulled too early.

Wow. This has not been my experience at all.

 

[ZincFingers]

Me neither. At my house, the attendings treat DNRs like anyone else and actually get annoyed if someone says "But should we be doing all this if they are DNR?"

And a palliation consult is seen as an admission of defeat.