Going to Hell

[AmoryBlaine]

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Truth is an absolute, and is independent of what others believe.

I'm guessing Absolute Truth just happens to coincide with what you believe though right?

 

[AmoryBlaine]

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.



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?

Just to clarify your point: do you believe that "forcing" a family to watch a code is ethically equivalent to a family desiring a full code on a medically futile patient?

I think there are some obvious points to be made about the simply massive discrepancy in medical knowledge between the two parties in question...

 

[DropkickMurphy]

Just to clarify your point: do you believe that "forcing" a family to watch a code is ethically equivalent to a family desiring a full code on a medically futile patient?

More or less.....I will give you a longer and detail answer later today. There is a meeting I need to get to.

 

[AmoryBlaine]

More or less.....I will give you a longer and detail answer later today. There is a meeting I need to get to.

I can't wait to disagree. 😀

 

[docB]

Sheeesh. I go away for a few days and just look at it! Benzoic- the hell I'm talking about here is being forced by guilty families and PMDs who wouldn't have "the talk" in timely manner forcing me to cause Granny to spend her last few moments of life in unspeakable pain due to breaking ribs and invading tubes. I, more than you could EVER imagine, did not intend to launch a religious discussion. Nope, didn't. Wouldn't. And certainly not on the EM board.
DKM and AB: good discussion. I would agree with AB that the starting post for that tangent, the one about having the family watch a purposefully long and grueling code is unethical IF it is being done just to impress upon the family the error of their decision. I nod to DKM's assertion that it would be nice to come up with some sufficiently dramatic way to educate families but I don't think that's it.

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.

This is a good point. But there are all kinds of "slow codes." Here's how I break it down. If you are not documenting accurately then you are doing something unethical. It's ethical to say that a case is medically futile and refuse to code. You will likely anger the family and can get sued (you can always get sued but going against the family raises your chances dramatically). You can also do CPR and one or two rounds of drugs and call it. Do BVM only and document that you are getting good ventilation insted of tubing. It's not great but 5 min of torture is better than 30. Document the horrible prognosis and futility of continuing on and call it. That's a justifiable and defensible "slow code" in my book.

 

[turtle md]

I usually say, "let's code grandma gently."

 

[AML]

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.

You scare me.

Not because you're a Christian...lovely faith, but that shoe doesn't fit my foot, no hard feelings... but because some day you're going to be standing across a counter and feeling morally superior as you say, "I'm sorry, my conscience doesn't permit me to refill your birth control prescription."
"I'm sorry, I won't fill that antibiotic prescription because it came from a women's clinic and they do abortions there and I can't support that."
"I'm sorry, I won't fill that prescription for emergency contraception because it's a violation of my conscience."
"I won't fill that prescription for an antiviral because you probably have an STD and should suffer the consequences of your immorality."

(all these have been said by "Christian" pharmacists, incidentally.)

That's not moral superiority. That's cruelty, sexism, and sometimes racism, disguised as faith.

 

[docB]

I find it a little amusing that an ER doc would feel that they should decide what is "best" for a patient they just met a few hours ago, even if it based on the opinion of a CT surgeon who just met the patient a few hours ago. Just out of curiousity, while the obviously terminal patient was still not coding, did anyone bother to ask her what her wishes were? Did you ask the family about any living wills or previous conversations with the patient in the hours leading up to this code? After hearing the pronouncement of the CT surgeons, did anyone sit down with the patient and/or family to discuss the stiuation?

Or (more likely) had you already walked away when CT came in, and didn't see the patient or family again until you heard the code get called?

You guys discuss this situation like you've known the patient for years, and have an ability to assess how they want to spend their final hours. Either that, or you are making the automatic assumption that everyone wants a "peaceful" death, and could have it if only their evil families weren't forcing you to torture them. But the truth is that, as ER docs, you are obligated to listen to your patients, or in cases of incapacitation, their families. Get over yourselves. This was never your choice, and thank God for that.

Wow! Where to begin? You are correct that it is not ideal for EPs to be faced with these decisions given our lack of a relationship with the patients and families. You are so incredibly wrong, arrogant, smug and misguided in everything else you said that it hurts my eyes just to read your silliness. We are in reality faced with this on a several times a day basis because of the laziness, callousness and general neglect of other doctors.

Now, on to your erroneous assumptions about this particular situation:
This code happened in the ICU, not the ED. I was called to deal with the s--t sandwich of a situation left to me by the primary, the critical care doc and the CT surgeon. Maybe they need to get over themselves? In any case, yes, they had all spoken to the family about the dire nature of the situation. The family was demanding the code. So I gave it to them.

I don't even know what to say about your assertion that not everyone wants a peaceful death. I will say that I can't imagine anyone asking for a grueling, painful, traumatic death when none of the interventions being done have a snowball's chance in Hell of helping. If you'd want that make sure it says so on your advance directives.

Finally here's why I can, do, and will continue to decide what's "best" for my patients despite my short relationship with them. That's what we do in ED, every patient, every day. I make a lot of quick decisions, intubation, cardioversion, etc. It is my choice. It is my judgement. Don't like it? TS.

 

[Jejton]

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...

I agree with the first statement but if you want to proceed with the second then logically, and in fairness, you should do the same to organ donors and those who donate their bodies to science ( aka medical schools, labs, Chinese take oh never mind that one, etc. ). You will soon find that you have an even greater shortage of donors.

 

[Jejton]

I find it a little amusing that an ER doc would feel that they should decide what is "best" for a patient they just met a few hours ago, even if it based on the opinion of a CT surgeon who just met the patient a few hours ago. Just out of curiousity, while the obviously terminal patient was still not coding, did anyone bother to ask her what her wishes were? Did you ask the family about any living wills or previous conversations with the patient in the hours leading up to this code? After hearing the pronouncement of the CT surgeons, did anyone sit down with the patient and/or family to discuss the stiuation?

Or (more likely) had you already walked away when CT came in, and didn't see the patient or family again until you heard the code get called?

You guys discuss this situation like you've known the patient for years, and have an ability to assess how they want to spend their final hours. Either that, or you are making the automatic assumption that everyone wants a "peaceful" death, and could have it if only their evil families weren't forcing you to torture them. But the truth is that, as ER docs, you are obligated to listen to your patients, or in cases of incapacitation, their families. Get over yourselves. This was never your choice, and thank God for that.

👍 This is a perfect example of why physicians need good handholding/communication/personal/call it what you want skills.

 

[sdn1977]

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.

I don't intend to flame you, but I will tell you that you need to get your priorities straight BEFORE you enter pharmacy school and I give you advice since I'm a practicing pharmacist.

We do indeed, as do all health professionals, have a conscious clause - but it is not on a case by case basis. For us, it is on a drug cased basis & you must decide AHEAD of time how you believe & if you believe in dipensing the drug under ANY circumstance, you will dispense the drug under EVERY circumstance. That means you must absoutely keep up on every drug with all its off label uses, in case you come across one you object to.

That means, if you will dispense misoprostol for GI effects secondary to NSAIDS, you'll also dispense it for cervical dilatation prior to an elective termination of pregnancy. Likewise, if you'll dispense Levora to a 30 yo married woman,you'll also dispense it to a 12 yo unmarried girl. There is no room for morality once you've signed AHEAD of time your own personal restrictions, which must be drug based.

Likewise...your obligation extends to giving the rx back to the pt & doing your best to find the medication &/or a pharmacist in the neighboring area which will fill it (& documenting you did so).

This is clear & uniform in all states, particularly after the Plan B debacle. You will be given a document to sign stating you have specific drugs you won't dispense or not. The company/corporation/hospital you work for will accept that & will assign you based on that staement.

I know of pharmacists who choose not to dispense certain drugs & have indeed written a disclaimer which allows them not to do so. However, this also limits their job opportunities. You will rarely be allowed to work alone.

You just must be aware of how your moral beliefs will limit your job opportunitites once you become licensed.

Once you become licensed, your morals will take a back seat unless you state up front and AHEAD OF TIME (this is the crucial part) that you will or won't dispense a drug. Otherwise, as a previous poster mentioned, it hinders appropriate tx & becomes a hurdle the patient & prescriber unnecssarily have to get over.

 

[deleted59964]

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 😳

umm - brain dead IS DEAD

 

[gro2001]

I don't intend to flame you, but I will tell you that you need to get your priorities straight BEFORE you enter pharmacy school and I give you advice since I'm a practicing pharmacist.

We do indeed, as do all health professionals, have a conscious clause - but it is not on a case by case basis. For us, it is on a drug cased basis & you must decide AHEAD of time how you believe & if you believe in dipensing the drug under ANY circumstance, you will dispense the drug under EVERY circumstance. That means you must absoutely keep up on every drug with all its off label uses, in case you come across one you object to.

That means, if you will dispense misoprostol for GI effects secondary to NSAIDS, you'll also dispense it for cervical dilatation prior to an elective termination of pregnancy. Likewise, if you'll dispense Levora to a 30 yo married woman,you'll also dispense it to a 12 yo unmarried girl. There is no room for morality once you've signed AHEAD of time your own personal restrictions, which must be drug based.

Likewise...your obligation extends to giving the rx back to the pt & doing your best to find the medication &/or a pharmacist in the neighboring area which will fill it (& documenting you did so).

This is clear & uniform in all states, particularly after the Plan B debacle. You will be given a document to sign stating you have specific drugs you won't dispense or not. The company/corporation/hospital you work for will accept that & will assign you based on that staement.

I know of pharmacists who choose not to dispense certain drugs & have indeed written a disclaimer which allows them not to do so. However, this also limits their job opportunities. You will rarely be allowed to work alone.

You just must be aware of how your moral beliefs will limit your job opportunitites once you become licensed.

Once you become licensed, your morals will take a back seat unless you state up front and AHEAD OF TIME (this is the crucial part) that you will or won't dispense a drug. Otherwise, as a previous poster mentioned, it hinders appropriate tx & becomes a hurdle the patient & prescriber unnecssarily have to get over.

I've been wondering a while how the conscience clause works for pharmacists... thanks for clearing it up.

 

[docB]

And this sends you to hell why? Oh, I get it. You wish you had the right to overrule the wishes of the family, who presumably have an understanding of what their loved-one wanted. In your perfect world, your judgement based on an hour's worth of interaction should trump that of a person's spouse or children.

But I'm smug and arrogant. Good one..

My point is that if these families understood the trauma and pain that their choice inflicted on their loved one WITH NO HOPE OF HELPING THEM they wouldn't choose it. In my experience most families when faced with the barbarity of the code that they have demanded ture pale and end the code once the ribs start to break.

All medical interventions buy time, including codes. Our better interventions give people years or decades. CPR, unfortunately, may give you days or hours on a vent, if you're critically ill. You might not find that valuable, but it should be obvious that other people do, for a variety of reasons.

Nope. A futile intervention like the one I had to participate in bought nothing. Just caused more suffering. What was that old saying about doing no harm? Oh well, I guess you wouldn't know.

Fortunately we're not in Europe, where death is the default answer from medical care. We err on the side of saving people, or at least trying to, as your original example makes clear.



Your story makes it clear that, despite your bluster, you will continue to do what the patient or surrogate tells you to do. Personally, I think that's a good thing. Sorry you're so conflicted over your chosen role.

You've clearly lost all sense of right and wrong. That's a shame. In medicine if you don't get conflicted now and then you've become a robot.

 

[McDoctor]

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.

If this is even actually true, I seriously doubt this was done on the basis of some deep philosophical or ethical code. Surely, this clown was just feeding off the thrill of having a wide-eyed pre-med fawning over his "cavalier" attitude. Give me a freaking break.🙄

 

[docB]

I never understood this argument. If their heart has stopped and their brain isn't oxygenating, then you're not hurting them, no matter how many needles and tubes you slam into them. It's only "barbaric" if you're watching it. If it's happening to you, it means nothing, because you don't have the faculties to feel pain. So what's the big deal?



Futile to you. Not futile to the husband, who can console himself that "everything was done" to keep their loved-one alive. Not futile to the children, who sleep a little better because they "never gave up" on mom. Not futile to the sibling, who made it just in time to the ICU after you tubed her to "say goodbye" before she died.

You and I know this is all silly, but for normal people who don't deal with this crap every day, it can mean a lot. It can buy time, and peace of mind. That's the whole point.

So when does it end? Am I obligated to code the patient forever if the family demands it? How about if they want me to hold off calling the code for 4 hours so a family mamber can get to the hospital while Grandma's still "alive?" Is there any situation in which you think witholding futile care is justified?

 

[Jejton]

I don't intend to flame you, but I will tell you that you need to get your priorities straight BEFORE you enter pharmacy school and I give you advice since I'm a practicing pharmacist.

We do indeed, as do all health professionals, have a conscious clause - but it is not on a case by case basis. For us, it is on a drug cased basis & you must decide AHEAD of time how you believe & if you believe in dipensing the drug under ANY circumstance, you will dispense the drug under EVERY circumstance. That means you must absoutely keep up on every drug with all its off label uses, in case you come across one you object to.

That means, if you will dispense misoprostol for GI effects secondary to NSAIDS, you'll also dispense it for cervical dilatation prior to an elective termination of pregnancy. Likewise, if you'll dispense Levora to a 30 yo married woman,you'll also dispense it to a 12 yo unmarried girl. There is no room for morality once you've signed AHEAD of time your own personal restrictions, which must be drug based.

Likewise...your obligation extends to giving the rx back to the pt & doing your best to find the medication &/or a pharmacist in the neighboring area which will fill it (& documenting you did so).

This is clear & uniform in all states, particularly after the Plan B debacle. You will be given a document to sign stating you have specific drugs you won't dispense or not. The company/corporation/hospital you work for will accept that & will assign you based on that staement.

I know of pharmacists who choose not to dispense certain drugs & have indeed written a disclaimer which allows them not to do so. However, this also limits their job opportunities. You will rarely be allowed to work alone.

You just must be aware of how your moral beliefs will limit your job opportunitites once you become licensed.

Once you become licensed, your morals will take a back seat unless you state up front and AHEAD OF TIME (this is the crucial part) that you will or won't dispense a drug. Otherwise, as a previous poster mentioned, it hinders appropriate tx & becomes a hurdle the patient & prescriber unnecssarily have to get over.

Um maybe I'm missing something but where did he/she state anything about dispensing or not dispensing drugs? Can one be a Christian and still give these drugs out? Just because this person feels strongly about Hell and immorality does not automatically mean we make the jump to saying he will not give out certain RX's.

 

[DropkickMurphy]

Surely, this clown was just feeding off the thrill of having a wide-eyed pre-med fawning over his "cavalier" attitude.

There was no wide eyed premed present and I certainly wasn't fawning over him (I happen to think he's a class A prick, albeit one who is a damn fine doc from a technical sense). You forget, I may be a premed in the strictest of terms, but I'm far from new to the medical field (and this happened during the several years I worked in hospitals before I ever decided to become a physician....at the time I was just the RT on duty and besides, most people who work with me have no idea what I do in my time away from work). My take on it was when he did this, it wasn't a strict code or anything, it was just the family had pissed him off and he thought they should be taught a lesson.

 

[kate_g]

...it was just the family had pissed him off and he thought they should be taught a lesson.

I know physicians are human too and all, but... yikes. That's a little more personal involvement than professionalism would dictate - to be so "pissed off" at a patient's family that you take it out on the patient by intentionally brutalizing them for longer than necessary, rather than doing your rational best to balance the family's wishes (please "do everything" to save grandma) with your knowledge (the code process is brutal; few codes on "hopeless" people actually succeed and those that do end up with worse quality of life than before you started).

Sorry, but from the outside looking in, you didn't get any closer to winning this guy's defense with that justification... Personally I think he could probably use some time with a counselor.

 

[DropkickMurphy]

Personally I think he could probably use some time with a counselor.

Yeah, I agree. A couple of the ED nurses (his wife being one of them) bought him a shirt that said "Got Thorazine?" as a joke. He's wound tighter than just about anyone I know and has a hair trigger temper. The term "raging dingus" has been used more than one- to his face- to describe him. The only redeeming factor is that he's also one of the best damn clinicians I've ever seen (total lack of bedside manner notwithstanding).

If you've ever seen the movie "Ghost and the Darkness", there's a description of the boss Beaumont that goes something to the effect of "I know Robert seems dreadful, but once you get to know him he's much worse. And I'm one of his defenders." That is basically how I feel about this doc.

you didn't get any closer to winning this guy's defense with that justification

I was mainly defending myself against the accusation of being a "wide-eyed premed" more than I was defending the doc's actions.

 

[Annette]

I never understood this argument. If their heart has stopped and their brain isn't oxygenating, then you're not hurting them, no matter how many needles and tubes you slam into them. It's only "barbaric" if you're watching it. If it's happening to you, it means nothing, because you don't have the faculties to feel pain. So what's the big deal?

Have you ever seen the distress on someone's face as they start to code? How do we know that they aren't feeling pain as the cells use up the last remainders of oxygen? After talking to hundreds of patients about how they see their deaths during my DNR speil, 99% tell me they want to go peacefully. Somehow, I can't see anyone believing that having your ribs broken into shards is even close to peaceful. NO ONE has told me that they wanted "futile" care.

Futile to you. Not futile to the husband, who can console himself that "everything was done" to keep their loved-one alive. Not futile to the children, who sleep a little better because they "never gave up" on mom. Not futile to the sibling, who made it just in time to the ICU after you tubed her to "say goodbye" before she died.

You and I know this is all silly, but for normal people who don't deal with this crap every day, it can mean a lot. It can buy time, and peace of mind. That's the whole point.

The trouble is people often don't have an understanding of what futile is. They see medical shows were people are coded for 1/2 minute, and wake up almost immediately with all their faculties intact. As for feeling better about not giving up, the physican talking and explaining what happened goes a long way. As for keeping a patient "alive" just to buy time is barbaric.

 

[ERMudPhud]

Last night I get a NH patient with respiratory arrest but still with a pulse and and BP. Paramedics are bagging her because they don't know what to do. She has a "CPR directive" in her chart. Unfortunately, although it is signed none of the boxes indicating what she would want(nothing, everything, etc...) are checked off. Someone forgot that important part. I spend the first 10 minutes of the code calling every family member whose name I can find in the chart to try to find out her wishes. Patient has severe CHF, renal failure, COPD, inoperable CAD. Even at her best she apparently can't walk 10 feet and has been bed ridden for months. Finally I decide I can't wait any longer and since no choices were actually checked on her advanced directives I tube her. She immediately stabilizes. 30 minutes before she goes to the ICU she wakes up and the look on her face is pure terror and pain. I put her back to sleep with some benzo's. Later the family arrives, tells the ICU she never wanted this and they decide to withdraw care. I'm pretty sure her last conscious thoughts were of terror and pain. A respiratory arrest in her sleep at the nursing home would have been much kinder. So much for Tired's thesis that the coding patient never feels pain. Sometimes they survive the code in pain only to die a little while later.

 

[EM_Rebuilder]

Just over a month inter intern year and I fell confident I jumped on the band wagon today...