Going to Hell

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docB

docB

Chronically painful
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95 yo F, end stage renal, chronic multi infarct dementia, bed ridden x 10 years, PEG and colostomy, septic from a huge vegetation on one of her valves, on dopa, levo, vasopressin drips, all maxed. CVT surgery told the family an hour before that the patient had no chance of survival. Family made me code her. Sure, I could have said no and claimed medical futility but I don't want to give up my days off for a year of depositions. So I coded her, short, but still. See ya in Hell.
 
docB said:
95 yo F, end stage renal, chronic multi infarct dementia, bed ridden x 10 years, PEG and colostomy, septic from a huge vegetation on one of her valves, on dopa, levo, vasopressin drips, all maxed. CVT surgery told the family an hour before that the patient had no chance of survival. Family made me code her. Sure, I could have said no and claimed medical futility but I don't want to give up my days off for a year of depositions. So I coded her, short, but still. See ya in Hell.
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This is an example of why the medical-legal system should be changed. I'm promised a "jury of my peers" if I go into court. Right now that's an impossibility. Medical malpractice cases should be decided by a panel of people who understand correct medical practice.

Unfortunately such a system would deprive the personal injury lawyers of much revenue, therefore politicians (being lawyers) will never allow it to happen.
 
GeneralVeers said:
This is an example of why the medical-legal system should be changed. I'm promised a "jury of my peers" if I go into court. Right now that's an impossibility. Medical malpractice cases should be decided by a panel of people who understand correct medical practice.

Unfortunately such a system would deprive the personal injury lawyers of much revenue, therefore politicians (being lawyers) will never allow it to happen.
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I had a great discussion with professor fetus about this. When she was in legal practice one of the plaintiffs attorneys said, why would you want tort reform? It would only limit your business. Hmm they are all against us!
 
docB said:
See ya in Hell.
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I feel your pain. I tell myself I'm going to hell for my complicity in this type of torture on at least a weekly basis.

Take care,
Jeff
 
docB said:
95 yo F, end stage renal, chronic multi infarct dementia, bed ridden x 10 years, PEG and colostomy, septic from a huge vegetation on one of her valves, on dopa, levo, vasopressin drips, all maxed. CVT surgery told the family an hour before that the patient had no chance of survival. Family made me code her. Sure, I could have said no and claimed medical futility but I don't want to give up my days off for a year of depositions. So I coded her, short, but still. See ya in Hell.
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that woman should come back and haunt her family. I'm constantly amazed at what families put their loved-ones through.
 
Depending on where you practice, at least you may get to send the "estate" quite a bill if you code her --think of the yummy critical care time!!! See you in hell...
 
Quimby2 said:
Depending on where you practice, at least you may get to send the "estate" quite a bill if you code her --think of the yummy critical care time!!! See you in hell...
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Not to mention all the billalble procedures for PEA such as CPR, emergent pericaridoentesis, bilateral darts, central line, intubation, etc. Hey, if the family wants everything, why not have them stand in the room while you do all these procedures so they can see what "everything" really means so they will have nightmares and eternal guilt for a really long time for what they put granny through....

See you there in hell!
 
docB said:
95 yo F, end stage renal, chronic multi infarct dementia, bed ridden x 10 years, PEG and colostomy, septic from a huge vegetation on one of her valves, on dopa, levo, vasopressin drips, all maxed. CVT surgery told the family an hour before that the patient had no chance of survival. Family made me code her. Sure, I could have said no and claimed medical futility but I don't want to give up my days off for a year of depositions. So I coded her, short, but still. See ya in Hell.
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The family will be joining you...
 
If it was an attending from CT, and your attending both think that it's medical futility, as long as you have 2 independent physicians state on the chart that it's medical futility, you don't HAVE to code the PT (or torture them etc), and can withdraw care as well (at least in NC)...check with your risk management team.

Our risk management team sees this constantly in the ICU's and their statement for a extremely similar case was, "get another MD to chart futility, and then you can withdraw". Apparently they see this almost daily (and seemingly are not concerned w/ it...and yes, this was with the family and their lawyer that they brought with them in the room...they really did bring the d-bag with them). It was kinda funny to see his face when our lawyers yawned and said, go ahead and do what you want, and they weren't concerned with our risk in the slightest...
 
I guess that you have to stop and ask, sincerely, "what is best for MY patient". Not what the family wants, not what their lawyer wants, but what can I do, at this point in time, is best for this patient.

Sorry, that was way hippy'ish, group hug, etc. Either way, do whats best for them.🙂
 
docB said:
95 yo F, end stage renal, chronic multi infarct dementia, bed ridden x 10 years, PEG and colostomy, septic from a huge vegetation on one of her valves, on dopa, levo, vasopressin drips, all maxed. CVT surgery told the family an hour before that the patient had no chance of survival. Family made me code her. Sure, I could have said no and claimed medical futility but I don't want to give up my days off for a year of depositions. So I coded her, short, but still. See ya in Hell.
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I heard of an orthopod who put a rod into the femur of a mentally ******ed and wheelchair bound kid that was hit by a car...a few days later he was pronounced clinically brain dead. The surgeon put the rod in anyways, the kid died two days later, and the surgeon was reported to the state medical board. The surgeon will not only be going to hell..but probably will have to smoke a turd when he gets there. Hope that makes you feel a little better docB 😳
 
TysonCook said:
I guess that you have to stop and ask, sincerely, "what is best for MY patient". Not what the family wants, not what their lawyer wants, but what can I do, at this point in time, is best for this patient.

Sorry, that was way hippy'ish, group hug, etc. Either way, do whats best for them.🙂
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Are you willing to go to court to back up your ethical viewpoint? Even if legally you can have two docs sign to withdraw support, there's nothing to prevent a family from launching a civil suit. I personally don't want to have to waste my time going to ANY court proceedings. I'd rather code grandma quickly and be done with it.
 
I gained a ton of respect for one of our EM attendings when this person said, "okay, we'll code her... but gently." Apparently when you see a sufficient number of these situations, you learn to sense where the lines are and avoid both the wrath of the family and the nastier parts of the "futile and brutal" type of code.

This spider-sense seems to take about 25 years to perfect, from my own unscientific research.
 
Actually, two wrongs DO make a right...you just have to multiply: (-)x(-)=(+). LOL!
 
Quimby2 said:
Actually, two wrongs DO make a right...you just have to multiply: (-)x(-)=(+). LOL!
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So then, theoretically,
((pressors) x 4 + bicarb gtts) x poor grandma x crazy family = me not going to hell along with y'all?

Oh hell, I'm there too. This one made my gut turn. I finally got the completely unreasonable family to let her be no-compression, and when she did code, I apologized to the code team for the bicarb I was about to give. Ended up getting her back (DOH), but finally sent to Jesus about 4 hours later... after a year in her family-imposed ICU hell.
 
spyderdoc said:
Not to mention all the billalble procedures for PEA such as CPR, emergent pericaridoentesis, bilateral darts, central line, intubation, etc. Hey, if the family wants everything, why not have them stand in the room while you do all these procedures so they can see what "everything" really means so they will have nightmares and eternal guilt for a really long time for what they put granny through....

See you there in hell!
Click to expand...
Just out of curiosity, what's the reimbursement rate for an emergent thoracotomy? :laugh:

My former medical director would make families watch the code if they pulled something like this and he would drag it out as long as possible.
 
DropkickMurphy said:
Just out of curiosity, what's the reimbursement rate for an emergent thoracotomy? :laugh:
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Less than that of a prophylactic DRE.

DropkickMurphy said:
My former medical director would make families watch the code if they pulled something like this and he would drag it out as long as possible.
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Good for him. I've been told that it is this reasoning as to why there has been a sharp decrease in unnecessary coding of the dead. People should be forced to see how we abuse and beat the crap out of people who are on their death bed.
 
TysonCook said:
If it was an attending from CT, and your attending both think that it's medical futility, as long as you have 2 independent physicians state on the chart that it's medical futility, you don't HAVE to code the PT (or torture them etc), and can withdraw care as well (at least in NC)...check with your risk management team.
Click to expand...
Some problems with that, #1 I was called from the ED to code the patient. It's happening now. The time for multiple signatures and consulting risk mgmt. is past. I'm the only doc in the hospital so the buck stops with me. #2 I can make the argument, on my own, that it's futile and stop the code, but they can sue and claim that in my 5 minute eval of the patient I couldn't possible make that determination. Now, we're all medical people and we all know that based on the original presentation this patient is not going to survive. What will a jury think? "He should have at least tried!" That's $50K.
 
DropkickMurphy said:
Just out of curiosity, what's the reimbursement rate for an emergent thoracotomy? :laugh:

My former medical director would make families watch the code if they pulled something like this and he would drag it out as long as possible.
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I doubt this very much.
 
docB said:
Some problems with that, #1 I was called from the ED to code the patient. It's happening now. The time for multiple signatures and consulting risk mgmt. is past. I'm the only doc in the hospital so the buck stops with me. #2 I can make the argument, on my own, that it's futile and stop the code, but they can sue and claim that in my 5 minute eval of the patient I couldn't possible make that determination. Now, we're all medical people and we all know that based on the original presentation this patient is not going to survive. What will a jury think? "He should have at least tried!" That's $50K.
Click to expand...

I agree with you. I'm just stating that if you are in the ICU, or the crumping lady that has been in/out of the ED 43 times in the last month, CAN be called futile (the chioce is open). I understand the fear of lawsuits (my father is a lawyer and does some med/mal), but at the same time a reasonable educated guess of what to do with the 94 yo 'shouldve been dead 4 years ago' code entails is necessary. I'd say I'm referring more to crititcal care where this scenario happens a lot, (family wants everything done, no matter what, and threatens lawsuits etc even though there is zero chance of medical recovery).

100% with what you did as far as the code etc, I'm just stating that if we feel strongly that the code is inappropriate, then there are other avenues. (as well as if the pt is a DNR, and daughter #1 says run the code, and you do, that = assult which you can go to court over as well). At least we'll see each other in hell with the attorneys 🙂
 
Drivers license often list a patient as yay or nay to Organ Donation... why can't we get DLs to start listing DNR status?

Show a video of a code and have a physician speak about the chances of outcomes and such... have to watch the video every 3rd time you renew the license....

I know not ever single person has a license, but its safe to say that the majority does...
 
Doubt whatever you like. He did not outright tell them they had to stay, but he would tell someone- normally one of the hospital security guards assigned to the ED- to shut the door to the trauma room and that effectively kept the family in there for the duration.
 
I'll probably get flamed for this, but that's ok. You'll go to Hell if you reject Christ and His payment for everyone's immorality regardless of what you did in this life.
 
Benzoic Acid said:
I'll probably get flamed for this, but that's ok. You'll go to Hell if you reject Christ and His payment for everyone's immorality regardless of what you did in this life.
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Ah, I probably should go ahead and book my ticket then.
 
DropkickMurphy said:
Doubt whatever you like. He did not outright tell them they had to stay, but he would tell someone- normally one of the hospital security guards assigned to the ED- to shut the door to the trauma room and that effectively kept the family in there for the duration.
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That's hugely unethical.
 
docB said:
Some problems with that, #1 I was called from the ED to code the patient. It's happening now. The time for multiple signatures and consulting risk mgmt. is past. I'm the only doc in the hospital so the buck stops with me. #2 I can make the argument, on my own, that it's futile and stop the code, but they can sue and claim that in my 5 minute eval of the patient I couldn't possible make that determination. Now, we're all medical people and we all know that based on the original presentation this patient is not going to survive. What will a jury think? "He should have at least tried!" That's $50K.
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I wonder if it should be a rule that half of the jury need to be medical professionals on a medmal case.
 
It all depends on your frame of reference. I think you're definitely going to hell for trying to prosyletize in this bulletin board. See you after the Rapture.

Benzoic Acid said:
I'll probably get flamed for this, but that's ok. You'll go to Hell if you reject Christ and His payment for everyone's immorality regardless of what you did in this life.
Click to expand...
 
Benzoic Acid said:
I'll probably get flamed for this, but that's ok. You'll go to Hell if you reject Christ and His payment for everyone's immorality regardless of what you did in this life.
Click to expand...

Sigh....even more proof we all came from monkeys. I guess some of us have come further than others.:meanie:
 
Benzoic Acid said:
I'll probably get flamed for this, but that's ok. You'll go to Hell if you reject Christ and His payment for everyone's immorality regardless of what you did in this life.
Click to expand...
17538331.gif
 
Benzoic Acid said:
You'll go to Hell if you reject Christ
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I guess I am OK then since I saw 2 self pay Jesuses today (one with chronic back pain, and one with an appy) that I could not reject because EMTALA says I can't.....
Oh wait, I'm Jewish, so I guess I'm screwed either way! Oh well, see ya in Jewish hell I guess....
 
DropkickMurphy said:
So? I don't see any difference in the degree of departure from accepted ethics in that than what the family expected DocB to do.
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Uhhh, are you kidding? To "force" patients to watch medical procedures is not ethical. Whether or not you should be coding their loved one is a separate issue entirely.

That's like saying, "well Mrs. Jones I'd be happy to do this transplant on your son but you must stand next to me and observe the whole time."
 
spyderdoc said:
Oh well, see ya in Jewish hell I guess....
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According to one of my jewish colleagues that place is a town without a chinese restaurant 😉
 
RogueNine said:
They are not patients.
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I think that was a simple typo, and I got what Amory was saying. While I do see his point, I do not agree with his analogy or assessment of the situation anymore than he agrees with mine.

To "force" patients to watch medical procedures is not ethical. Whether or not you should be coding their loved one is a separate issue entirely.
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I did not say they were the same issue. I said the degree of ethical violation was similar in my opinion. Anyone else care to chime in?
 
DropkickMurphy said:
Anyone else care to chime in?
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Meh. The attendings where I work seem to prefer not having family in during a code if they had the choice. They don't lock family in or kick them out. If family is there, fine...if not, fine.
 
I believe this is where the term "show code" comes from.
I recently sat on the bed of a man with terminal lung ca who didn't tell his wife what he wanted, (dnr, etc) and cursed him for it as I nasal tubed him. It's one thing to be proud but its another to not want to suffer and waste away. It's not like we could have with held care in EMS from this patient but the wife could have known to let him go.
 
bartleby said:
It all depends on your frame of reference. I think you're definitely going to hell for trying to prosyletize in this bulletin board. See you after the Rapture.
Click to expand...

No it does not depend on your frame of reference. It all depends on the truth.
 
emtcsmith said:
I believe this is where the term "show code" comes from.
Click to expand...

A 'no code' for futility is a justifiable professional decision. A 'slow code' is an invitation for one of your ancillary staff to rat you out to the family inviting a lawsuit.
 
Benzoic Acid said:
I'll probably get flamed for this, but that's ok. You'll go to Hell if you reject Christ and His payment for everyone's immorality regardless of what you did in this life.
Click to expand...

You DO deserve to get flamed, because there's the two "hells" - the literary, "Paradise Lost" version (which is what we - well, except you - are speaking of here), and the real one that Christians and others speak of and believe in, and that you are (mistakenly) proselytizing about here.

You get -1 points for being obtuse and moderately dunderheaded.
 
Benzoic Acid said:
Truth is an absolute, and is independent of what others believe.
Click to expand...
...and yet believing that to be true must be an article of faith, since there is no way our human cognition can prove it beyond a doubt. And anyway, as we in Emergency Medicine know as well as anyone on earth, we all have to deal with one another, and so we're going to need to compromise a little on the objective absolutes if we're going to find some imperfect, human basis for getting along.

So please. Don't let's get all Thomas Aquinas in here. This is not the place for it, and anyway there is a perfectly good discussion about something else already going on here. Start a new thread if you really care to hear what a bunch of emergency people think of the literal idea of Hell.
 
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