Future Physicians - I want your input

[keyslammer]

---

Members do not see this ad.

OK, I'm not a physician or even soon to be physician. I am a member of the team who is called patient care, being a medical transcriptionist with 27 years experience.

When you all (as students) see a patient in the ICU, who has BEEN in the ICU for a month with so many things wrong chronically and then they are there with no insurance, no family, no nothing, what do you think? I really want to know. I don't know if the new government healthcare is going to make recommendations (suggestions) or if they will say to just pull the plug. Here is an example of what I'm talking about. I know I run the risk of being thought of as thoughtless and uncaring but nothing could be further from the truth. I DO care and it just seems that this person has NO quality of life and no future hope for a quality of life. Is it hard for you to continue treating folks like this or do you just do it mechanically with a feeling that you MUST do this.

Here is what I just transcribed.


</OBJECTIVE/>
Vital signs: Blood pressure was 115/52, pulse rate 78, respiratory rate was 20. Temperature was 99.3, oxygen saturation 98% on 40% BiPAP. She is on a heparin drip per protocol. She is tolerating tube feedings at 50 mL per hour. She made 1440 mL of urine on the midnight shift. The patient moans and says single word answers. Does not reliably follow commands. Moves all extremities.
Chest: Lung sounds are coarse, nonproductive cough.
Heart: Regular rate and rhythm, dependent edema persists.
Neck: Left side PICC line in place.
Abdomen: The patient had a "loose normal" stool reported about 8:00 o'clock this morning.

</PERTINENT LABORATORY DATA/>
White blood cell count 5.6, hemoglobin 8.1, platelets 209,000. PTT was 43.9 at 2:00 o'clock this morning, 92.7 at 10:00 o'clock this morning. Sodium 151, potassium 3.2, chloride 119, CO2 of 22. The BUN was 63 yesterday. Creatinine was 4.28 yesterday. Glucose this morning was 253. Serum osmolality was 342 this morning. Iron level yesterday was 12. Urine osmolality is low at 213. Blood culture from 04/20/2010, is negative x2. Blood cultures from 04/13/2010, are negative. Stool for Clostridium difficile is negative.

</IMPRESSION/>
1. Status post acute respiratory failure.
2. Septic shock.
3. Urinary tract infection. Gram negative organisms as well as yeast on admission.
4. Acute renal failure, metabolic acidosis and hypokalemia.
5. Diabetes insipidus with hypernatremia.
6. Right upper extremity deep venous thrombosis on heparin drip.
7. History of morbid obesity, approaching calorie malnutrition, anasarca. The patient has a failed swallow evaluation.
8. Iron deficiency anemia, anemia of chronic disease.
9. Uncontrolled insulin dependent diabetes mellitus.
10. History of appendectomy, hysterectomy.
11. Gastroesophageal reflux disease.
12. Schizophrenia.
13. Multiple sclerosis, for which the patient has been bedridden.
14. Previous deep venous thrombosis.
15. Right-sided PICC line. April 8, 2010, discontinued after the development of the deep venous thrombosis and left PICC line was placed on April 19, 2010.
16. History of angioplasty.
17. Chronic kidney disease stage 4.

</RECOMMENDATIONS/>
1. Transfuse packed red blood cells as needed to maintain adequate oxygen carrying capacity.
2. Insulin per protocol.
3. Atrovent, albuterol breathing treatments.
4. Intravenous iron.
5. Epogen stimulated red cell production.
6. Lantus plus sliding scale insulin coverage.
7. Start desmopressin 1 spray twice daily to control the patient's diabetes insipidus.
8. Protonix for GI prophylaxis.
9. Continue dilantin for seizure control.
10. Intensive care unit care plan.
11. Aggressive pulmonary toilet.

How is it "right" to go on letting this person live? I don't understand the theory of it. I mean are we not playing God to keep them alive with all these mechanical and artificial means?

 

[Depakote]

what did the patient indicate they wanted in this situation? Failing that, what does the family want?

My team put people who were in worse shape than the one you described through the ringer on my pulm/critical care rotation. I would have thought they should have been on hospice, but they were with it enough to say they wanted everything done and they wanted to attempt a meaningful recovery. So we gave them every opportunity to do so.

 

[keyslammer]

I was looking back on previous reports and it mentioned the patient had no family, was living in a nursing home prior to hospitalization. She has no living will and apparently has not been able to communicate any wishes for years. A report back in 2005 indicated she just grunts and groans.

I just don't see the point. It's sad when nobody is there for them like this to help make the decisions as to what would be best for them. I mean this woman will never be able to communicate her wishes obviously. I'm sure there are a lot of people who are in much worse condition than she is, living artificially for long periods of time simply because they don't want to die.

I value life as much as anyone, but it just seems that if someone is going to be chronically ill to this extreme what is the purpose? Seems like it would be more caring to just let them go than to rack up thousands upon thousands of dollars of care and the physicians who work so diligently to keep them alive will probably never see a dime for it. You guys are awesome in your dedication, especially in taking care of folks like this lady, knowing you will never get paid for doing so.

I appreciate your comments. Thanks much!🙂

 

[vicinihil]

Death you shall have, but first, a little Mamba.

 

[keyslammer]

LOL.....thanks, I needed that laugh and confirmation.😀

 

[cpants]

Yes, there are a lot of sad cases out there. Basically you just do the best you can and try to determine what the patient would have wanted. It's hard to know what the best course of action is, but I do not want a team of bureaucrats deciding what should be done with patients under my care. Better to seek out family, evaluate the medical situation and whether or not further care is futile, and then make your best decision.

 

[ACSurgeon]

Apparently studies have shown that most older adults would rather NOT be in the ICU or have life support when they are dying (as most ICU patients are). So, while physicians and family members do "everything" possible to keep folks alive, it is much more likely than not the opposite of what the patient would actually want. Not to forget it adds up to billions of dollars every year to finance this futile care.

 

[bsteven2]

very harsh and unrealistic in our society, but the Inuit leave their elders that cannot provide for the community with the wolves...saves lives in the community and takes out the subjectivity of "what would this person want".

 

[phospho]

the Inuit leave their elders that cannot provide for the community with the wolves...saves lives in the community and takes out the subjectivity of "what would this person want".

Definitely a myth. I've read a lot about them. Not that wikipedia is something to quote, but they do have good citations for this:

A pervasive European myth about Inuit is that they killed elderly and unproductive people.",[47] but this is not generally true.[48][49][50] In a culture with an oral history, elders are the keepers of communal knowledge, effectively the community library.[51] Because they are of extreme value as the repository of knowledge, there are cultural taboos against sacrificing elders.

http://en.wikipedia.org/wiki/Inuit

 

[Bitsy]

What I don't get is why was the patient admitted into the ICU in the first place? Maybe I'm biased because I worked in a public hospital in the 3rd world country, but over here, they only let a person into the ICU that actually might have a chance to survive. The few patients over age 60 I've ever seen in the ICU only had 1 disease (a heart attack or cetoacidosis) and didn't have other problems which improved their survival rates enough to be accepted.

Patients that had end stage kidney failure, end stage liver disease, massive infections on an old and already bedridden patient were usually just sent to hospitalization to be given palliative care knowing they are going to die anyways. The chances of entering the ICU unit for this woman in a public hospital in Mexico would have been null (though I have no idea what her age is which might have been why they accepted her if she was under age 50), especially since she has no known family members and has been severely impaired for at least 5 years. Having end stage multiple sclerosis would have probably never made her eligible to get accepted into an ICU.

And now that she's been there for 1 month with probably no chances of recovery, the hospital is now stuck with her and will have to absorb the costs of her care. An ICU unit can only discharge a patient to hospitalization if they are recovered enough to warrant it, she will have to stay there until she passes away. This case sounds more like a case of poor judgment of admitting patients into the ICU which usually relies either on specific physicians that will accept everyone no matter what or poor hospital policy. At the end the hospital if it's smart will change policies to make it harder for terminal patients to enter the ICU service because the cost:benefit isn't worth it.

I'm perplexed, doctors don't make the clinical notes themselves? The note seems to lack a lot of physical exploration parts (like.. most of it).

Well, this is definitely not how ICUs in the United States works. The majority of the patients in major ICUs in the US are over the age of 60 and have multiple co-morbidities. So your comments don't really pertain to how things work here. In most circumstances, patients are only on palliative care with the consent of the patient or if the patient is unable to make decisions for himself/herself, the power of attorney (preferably) or family must consent to palliative care. Oh, and the doctors do the clinical notes. Sometimes, they dictate and medical transcriptionists type out their notes.

 

[ACSurgeon]

Well, this is definitely not how ICUs in the United States works. The majority of the patients in major ICUs in the US are over the age of 60 and have multiple co-morbidities. So your comments don't really pertain to how things work here. In most circumstances, patients are only on palliative care with the consent of the patient or if the patient is unable to make decisions for himself/herself, the power of attorney (preferably) or family must consent to palliative care. Oh, and the doctors do the clinical notes. Sometimes, they dictate and medical transcriptions type out their notes.

Not true for ICU's. I was at a presentation that quoted a study with a conclusion of 75% or so of ICU patients would rather not be there. I guess families might be consenting in most of these cases, but I don't see how that's any better if the patient wouldn't want it (but just never put it in writing).

 

[cpants]

Not true for ICU's. I was at a presentation that quoted a study with a conclusion of 75% or so of ICU patients would rather not be there. I guess families might be consenting in most of these cases, but I don't see how that's any better if the patient wouldn't want it (but just never put it in writing).

I'm sure 100% of ICU patients would rather not be there. The question is do they want to change to comfort care? You always hear these quotes, but how do they determine for a study what the patients wanted when we can never get that information at the time and would gladly transfer them out if only we had the go ahead. Are they basing it on population surveys?

 

[Bitsy]

Not true for ICU's. I was at a presentation that quoted a study with a conclusion of 75% or so of ICU patients would rather not be there. I guess families might be consenting in most of these cases, but I don't see how that's any better if the patient wouldn't want it (but just never put it in writing).

I'm confused by your statement in response to my post. I think you need to reread my post. I'm not saying that patients consent to be in the ICU. They have to consent to be put on palliative care aka comfort measure only. If they don't have a living will or power of attorney saying they don't want ICU care, they will likely be put in the ICU to receive aggressive treatment. What I was saying is that unlike Mexico, you can't just put people on palliative (comfort care only) measures simply because they have multiple comorbities. You usually have to consent to comfort measures. There are some exceptions, but those usually get messy and ethics committees are involved (if the family disagrees anyway).

 

[MattD]

In response to the actual question, I guess my opinion on giving this patient the full court ICU press is going to depend on the patient's history, ie. how many of the mentioned problems were being reasonably well controlled outside of the hospital in the chronic setting, what the acute event was precipitating the admission, and whether that condition is reversible. Just because someone is in the ICU with 13 co-morbidities doesn't mean they are a 'train-wreck', if 12 of those co-morbidities were chronic problems that were well controlled before #13 whacked them.

Separately, that note looks just a wee bit like a cut and paste from an actual patient's chart. Is this really appropriate to post on the internet, lack of patient-specific identifiers notwithstanding?

 

[subdominant]

Keyslammer,

In the great words of Chester the Cheetah, "It ain't easy bein' cheesy." And by bein' cheesy I mean havin' clinical responsibility.

Sincerely,
Eight Days of Medical School To Go.

 

[ACSurgeon]

I'm confused by your statement in response to my post. I think you need to reread my post. I'm not saying that patients consent to be in the ICU. They have to consent to be put on palliative care aka comfort measure only. If they don't have a living will or power of attorney saying they don't want ICU care, they will likely be put in the ICU to receive aggressive treatment. What I was saying is that unlike Mexico, you can't just put people on palliative (comfort care only) measures simply because they have multiple comorbities. You usually have to consent to comfort measures. There are some exceptions, but those usually get messy and ethics committees are involved (if the family disagrees anyway).

My bad. I guess we were saying the same thing

 

[ACSurgeon]

I'm sure 100% of ICU patients would rather not be there. The question is do they want to change to comfort care? You always hear these quotes, but how do they determine for a study what the patients wanted when we can never get that information at the time and would gladly transfer them out if only we had the go ahead. Are they basing it on population surveys?

Yes. If I'm recalling correctly it was whether they would rather be in the ICU or receive comfort care only. I'm not too clear on the details. At any rate, this study was pushing for advanced directives making the claim that if people made their wishes clear ahead of time, they could be spared invasive (potentially futile) interventions that cost a ton of money.

 

[LadyWolverine]

Not true for ICU's. I was at a presentation that quoted a study with a conclusion of 75% or so of ICU patients would rather not be there. I guess families might be consenting in most of these cases, but I don't see how that's any better if the patient wouldn't want it (but just never put it in writing).

And therein lies the problem - it was never put in writing. Therefore, from a legal standpoint, it doesn't exist. Despite the fact that it may be the patient's wishes, and the family may know and agree to honor said wishes, no doctor is going to make a life-or-death decision (regardless of the quality or quantity of life left) based on a "feeling." "Feelings" do not stand up in court - documents will. So, instead we admit to ICU and "do everything" until someone signs the DNR/DNI and palliative care consent.

It's one thing to ask people who are otherwise well (that is, not in the ICU at the time) what they would want if it came to ICU vs. palliative measures. Given the hypothetical situation "...If you were so far gone that you had 100 things wrong with you and no reasonable chance for a meaningful recovery, would you rather be in the ICU having everything done for you, or would you rather die peacefully at home/in hospice/etc?" When phrased that way, so that you already know the inevitable outcome, OF COURSE everyone says they wouldn't want to die in the ICU.

However, it's a whole different ballgame when it's your (or your mom's, or your spouse's) turn to step up to the plate. You don't KNOW the outcome. Suddenly, instinct to survive takes over, and you want to believe that you (or they) are going to be that one-in-a-million miraculous case that we overdramatize on TV (and thus the reason people have such unrealistic expectations). And, because most folks don't have a living will or POA available when they come into the ED, the defualt is to "do everything" and send the person to the ICU for aggressive care. That is, until the family finally breaks down after 1-2 weeks and, step-wise, agrees to withdraw more and more aggressive care measures.

I understand why we torture the for-all-intents-and-purposes-dead in this country. It's because we're afraid. And because, deep down, we all want to witness a miracle. Unfortunately, it's very expensive to undergo this process and ultimately has no impact on the patient's QOL or longevity. It's also very difficult for families to have to make these decisions to, in their mind, "kill" their loved one by removing life-sustaining measures. Even if all that's lying in a hospital bed is a shell that is dependent on PEG/trach&vent/HD/ECMO/whathaveyou - they are still technically "alive" so we can sit around...waiting for them to die.

It should be a requirement for everyone over the age of 18 to have a living will/POA, and to update it at least every year.

 

[Law2Doc]

OK, I'm not a physician or even soon to be physician. ...

How is it "right" to go on letting this person live? I don't understand the theory of it. I mean are we not playing God to keep them alive with all these mechanical and artificial means?

Unless I'm missing something this patient is actually not that bad off for an ICU patient. The patient is hemodynamically stable, not requiring pressors. Afebrile with no white count (despite the diagnosis of septic shock, which doesn't seem to be supported by the rest of the data). Is on BiPap, not on the vent. Has acute on chronic renal failure but is making urine. Couple of the labs are a bit off but correctable. Patient is at least partially neurologically intact and verbalizing, nothing in the synopsis to suggest brain damage beyond the MS. I guess I'm missing what specifically in this example is going to imminently kill the patient that we should be talking about "pulling the plug"? The kidneys are shot but we keep numerous people alive for a long time without their original kidneys. Lungs aren't great but the patient isn't requiring the vent, so that puts them ahead of half the ICU patients on that account. This sounds like the type of patient that you optimize and transfer off to a nursing home, not a very long ICU stay, and probably someone who won't be dying during this hospital admission. Honestly, if you are going to make your point on this, you need to pick a sicker patient, not a "routine" ICU patient, IMHO.

 

[wordjunkie]

Separately, that note looks just a wee bit like a cut and paste from an actual patient's chart. Is this really appropriate to post on the internet, lack of patient-specific identifiers notwithstanding?[/QUOTE]

As a medical language specialist (new fancy title for medical transcriptionist), I found myself wondering the same thing as I was reading the original post. I know this is a rarefied community and the chances of anybody recognizing the patient by the details in this post are slim, they still do exist. And, barring that, I am concerned about the poster's understanding of what patient privacy means. I know there are times in our work when we must divulge certain details, but that was a LOT of information about one particular patient. And, it was certainly not done in conjunction with the job. Kinda scary.