Letting your fellow/resident work on someone despite probable futility...

[CodeBlu]

Hey,

I recall reading something about a NICU attending letting a resident work on and keep a baby alive overnight... meanwhile the attending knew the patient was going to die.

I had something similar happen in the adult world. It's infinitely easier to let go there on a 90 year old. I would have stopped care on this patient in their early 70's and had a palliative discussion. Instead, got re-intubated and then LVEF 5% from the 10% it was... for whatever that's worse. On massive doses of vasopressors and inotropes. Family "wanted everything done"... I recommended to my attending that we stop. And they said no, keep going...

I'm sure there is a lesson in here somewhere... as in, none of us are god. We should try to save them?

Just wondering if you guys had any similar experiences that you had gone through...

Have a good rest of the weekend everyone!

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[Hernandez]

How do you know what is futile if you haven’t see it fail?

 

[chocomorsel]

How do you know what is futile if you haven’t see it fail?

By seeing it fail repeatedly in other candidates with the same type of critical illnesses. I bet it wasn’t just an EF of 5% that was going on in this patient.
OP we need the whole story. Not just the EF.

 

[deleted547339]

By seeing it fail repeatedly in other candidates with the same type of critical illnesses. I bet it wasn’t just an EF of 5% that was going on in this patient.
OP we need the whole story. Not just the EF.

Do you though?

 

[Radetzky]

Do you though?

lol unless this is something like myocarditis, an EF of 5% tells the whole story

I’m impressed you actually got a specific number. Usually at < 10 they stop reporting the specific number

 

[chocomorsel]

lol unless this is something like myocarditis, an EF of 5% tells the whole story

I’m impressed you actually got a specific number. Usually at < 10 they stop reporting the specific number

Did not know that. But then again I’ve never seen an echo with less than 10% give me a specific number. Just never thought about it.

 

[chocomorsel]

Do you though?

I really don’t. I was really only doing it for @Hernandez since he was playing devil’s advocate.

 

[Hernandez]

By seeing it fail repeatedly in other candidates with the same type of critical illnesses. I bet it wasn’t just an EF of 5% that was going on in this patient.
OP we need the whole story. Not just the EF.

I believe you kinda made my point for me.
I believe there is a role for some futile care..... in a teaching institution, for trainees to see how little we can do in these situations to carry that forward when having family discussions on survivability.

I remember when I was a trainee, I was a 3rd year fellow and after a 45 minute code I walked out and asked my attending I was friends with WTF are we doing? The guy was dead, wasn’t survivable. His reply was this is a teaching institution, get the **** back in the room, put in yet another chest tube and keep going until I was told to stop. S.o.b, the 5th chest tube kept the lung inflated enough the guy didn’t die any more and he actually walked out of the hospital a few weeks later after already having a protracted stay. It’s a fine line between futile or not and unfortunately that necessitates trainees to see piles of futile care to try and discern where the line is.

 

[MoMoGesiologist]

I believe you kinda made my point for me.
I believe there is a role for some futile care..... in a teaching institution, for trainees to see how little we can do in these situations to carry that forward when having family discussions on survivability.

I remember when I was a trainee, I was a 3rd year fellow and after a 45 minute code I walked out and asked my attending I was friends with WTF are we doing? The guy was dead, wasn’t survivable. His reply was this is a teaching institution, get the **** back in the room, put in yet another chest tube and keep going until I was told to stop. S.o.b, the 5th chest tube kept the lung inflated enough the guy didn’t die any more and he actually walked out of the hospital a few weeks later after already having a protracted stay. It’s a fine line between futile or not and unfortunately that necessitates trainees to see piles of futile care to try and discern where the line is.

This story goes to show we don’t always know who is gonna do poorly and who will do well... code all the patients! Even the 90 year olds with EF 5%!

 

[vector2]

lol unless this is something like myocarditis, an EF of 5% tells the whole story

I’m impressed you actually got a specific number. Usually at < 10 they stop reporting the specific number

For those not in the know, the vast majority of EF% in a TTE report are just visual estimation by the cardiologist. After seeing 10,000 studies you get a good idea what 35% vs 45% looks like.

If someone is doing it quantitatively, typically it's calculated by using Simpson's method of discs, either doing a manual trace or automated software. Neither method is accurate down to within a few percent unless you have an excellent quality study, likely using contrast, and are meticulously tracing the endocardial borders.

The TLDR version is that there's pretty much no difference in clinical mgmt if the report says 10%, 5%, or <10% etc

 

[sluggs]

I'm hearing 2 separate issues here:
1. When is care actually futile?
2. If care is, in fact, futile, should trainees be allowed to continue resuscitation as a learning experience.

With respect to 1, definitions and perspectives vary, but one think I focus on is the patient's pre-hospital condition. If someone was doing ok and having some quality of life immediately prior to the catastrophic illness, I will take the longest of long shots/throw "hail Marys" much more readily than on someone who was elderly, demented, nursing home bound, with a long-standing trach and peg. With regard to a medical definition of "futile", I have seen the conjecture that if in the last 100 cases of condition or state X, no one has survivied, it is a futile condition/'state. I personally try the definition: "if things go perfectly this person has no likelihood of surviving to discharge with any quality of life, the case is futile." Of course, depending on other factors, families often correctly want less aggressive care even if the case is not futile.
For 2, if a patient is not suffering (too far gone to feel) and the family has not stopped care, I will sometimes let my residents continue resuscitation.
This is just my thinking.

 

[Siggy]

For those not in the know, the vast majority of EF% in a TTE report are just visual estimation by the cardiologist. After seeing 10,000 studies you get a good idea what 35% vs 45% looks like.

If someone is doing it quantitatively, typically it's calculated by using Simpson's method of discs, either doing a manual trace or automated software. Neither method is accurate down to within a few percent unless you have an excellent quality study, likely using contrast, and are meticulously tracing the endocardial borders.

The TLDR version is that there's pretty much no difference in clinical mgmt if the report says 10%, 5%, or <10% etc

For quantitative and POCUS, I'm a fan of fractional shortening (our Sonosite will convert FS to EF and display both values). Simpson's takes too long to do.

 

[NITRAS]

I heard a rumor at my med school that a guy who came in with a gunshot wound to the head had chest tubes and central lines placed under a stopwatch. Again a rumor, but not that hard to believe.

We do a lot of futile care. I had a lady couple weeks ago. Cancer, clots, bleeding, malignant effusion......told her she shouldn’t be full code. Two weeks later, I got to pronounce her after another 9 days in icu.

 

[vector2]

For quantitative and POCUS, I'm a fan of fractional shortening (our Sonosite will convert FS to EF and display both values). Simpson's takes too long to do.

It takes a long time because it's accurate. If you're just doing POCUS/eyeballing then FS will spit out a number if you really need one, but in comparator studies with MRI you'll miss about 40-50% of people who have a truly decreased EF (i.e. pt has RWMAs in a distribution where you're not acquiring FS measurement images). In a POCUS exam, you're better off doing fractional area of change using a mid pap short axis. Doesn't take too much longer and is def more accurate.

Ascending order of accuracy for anyone interested:

Fractional shortening
Fractional area of change
2d Simpson's
3d TTE/TEE volumetric
High res cardiac CT (>128 slice, excellent breath hold)
Cardiac MRI (gold standard)

 

[deleted547339]

It takes a long time because it's accurate. If you're just doing POCUS/eyeballing then FS will spit out a number if you really need one, but in comparator studies with MRI you'll miss about 40-50% of people who have a truly decreased EF (i.e. pt has RWMAs in a distribution where you're not acquiring FS measurement images). In a POCUS exam, you're better off doing fractional area of change using a mid pap short axis. Doesn't take too much longer and is def more accurate.

Ascending order of accuracy for anyone interested:

Fractional shortening
Fractional area of change
2d Simpson's
3d TTE/TEE volumetric
High res cardiac CT (>128 slice, excellent breath hold)
Cardiac MRI (gold standard)

lolz....

dude, all I care about is whether or not it’s cardiogenic shock at 2AM and I can’t get an echo until 8.

 

[vector2]

lolz....

dude, all I care about is whether or not it’s cardiogenic shock at 2AM and I can’t get an echo until 8.

Yea I get it. My response was aimed at the ppl who might wonder where 'EF 10%' in a formal report actually comes from, and also toward anyone studying for the cceexam

 

[Siggy]

It takes a long time because it's accurate.

I get that it's the most accurate, but when I'm simply am looking for an image that I can paste into the chart (since we can't upload to PACS, but there's a way to upload static images to Cerner) FS gives me what I'm looking for. I just had a thyrotoxicosis with tachycardia induced cardiomyopathy where the EF went from 20-25% to 50% between getting control of the heart rate and the formal echo. The EF was why I went with esmolol instead of propanolol.

 

[Doctor Bob]

I remember hearing a saying in the trauma world...

We practice on the 80yr olds in order to save the 20yr olds.

There is a modicum of truth to that. It doesn't mean we should do things to a patient that we feel is futile or inappropriate... but it's often a consideration in the back of our minds when we put the 98yr old demented bed-bound bed-sore-ridden patient back on the ventilator when the family wants you to do everything. You might learn something from the case that you can use to save a later patient.

 

[Radetzky]

I remember hearing a saying in the trauma world...

We practice on the 80yr olds in order to save the 20yr olds.

There is a modicum of truth to that. It doesn't mean we should do things to a patient that we feel is futile or inappropriate... but it's often a consideration in the back of our minds when we put the 98yr old demented bed-bound bed-sore-ridden patient back on the ventilator when the family wants you to do everything. You might learn something from the case that you can use to save a later patient.

Do you not feel the situation you describe is futile and inappropriate?

If you fill up your ICU beds and your doctors and nurses time and brainpower with these kinds of futile cases and balloon insurance costs for everybody else, I believe this is far more detrimental to the potential 20 year old that you can do something for, than anything you could learn from someone who's physiology is completely different.

 

[Doctor Bob]

Do you not feel the situation you describe is futile and inappropriate?

If you fill up your ICU beds and your doctors and nurses time and brainpower with these kinds of futile cases and balloon insurance costs for everybody else, I believe this is far more detrimental to the potential 20 year old that you can do something for, than anything you could learn from someone who's physiology is completely different.

It's an anecdotal saying.
Don't take it so literally.

 

[engineeredout]

lolz....

dude, all I care about is whether or not it’s cardiogenic shock at 2AM and I can’t get an echo until 8.

Also actually trying to calculate a cardiac output probably matters more than the EF in many cases. Seen too many people get hung up on the reduced EF in someone with chronically reduced EF - it’s helpful to prove that their CO is adequate, they just need to treat sepsis instead of “cardiogenic shock”

 

[deleted547339]

Also actually trying to calculate a cardiac output probably matters more than the EF in many cases. Seen too many people get hung up on the reduced EF in someone with chronically reduced EF - it’s helpful to prove that their CO is adequate, they just need to treat sepsis instead of “cardiogenic shock”

Sure. Your baseline EF of 30% certainly confounds the issue - that’s when the rest of the picture (history, physical, source, labs, imaging, etc) as well as focused additional data (IVC, scvo2, bnp/trop, rarely a swan) and some subtly in clinical judgement become paramount.

 

[MEN2C]

I can speak from the NICU/Peds perspective (I'm a NICU fellow)...I think sometimes we do futile care for the sake of the parents. Not too long ago, I got called to the ED because parents got into a car accident and the mother died while pregnant (essentially died on the way to the hospital, they were doing compressions as they were wheeling her in). Dad was unharmed. It was initially unclear gestation, but then mom was 23 weeks per dad. OBs did a C/S in the ED while mom was getting resuscitated...I get a baby on the warmer. Definitely weighed less than 1lb (I initially estimated the weight between 350g-400g for code med purposes), and the baby looked younger than 23 weeks by appearance with a very barely perceptible heart rate.

Dad wanted everything. At this point, the chance of survival were almost zero, and the chance of survival without severe morbidity are worse than zero. But I continued - tubed the baby, did compressions, put in a central line and gave epi, put in a chest tube etc. Somehow got him back. Ended up needing lots of blood and other product, pressors etc. Almost ended up doing a pericardiocentesis later. Probably all of that for the sake of the family? The baby died later that night. On the face of it, we all kind of knew it was futile. But it's hard to lose both your wife and your unborn child in the same day. No one really would have blamed me if I had just wrapped up the baby and given him to dad to hold - and maybe that would have been the right answer? I am not sure. Would that have been kinder? I don't know what the right answer is.

 

[MoMoGesiologist]

I can speak from the NICU/Peds perspective (I'm a NICU fellow)...I think sometimes we do futile care for the sake of the parents. Not too long ago, I got called to the ED because parents got into a car accident and the mother died while pregnant (essentially died on the way to the hospital, they were doing compressions as they were wheeling her in). Dad was unharmed. It was initially unclear gestation, but then mom was 23 weeks per dad. OBs did a C/S in the ED while mom was getting resuscitated...I get a baby on the warmer. Definitely weighed less than 1lb (I initially estimated the weight between 350g-400g for code med purposes), and the baby looked younger than 23 weeks by appearance with a very barely perceptible heart rate.

Dad wanted everything. At this point, the chance of survival were almost zero, and the chance of survival without severe morbidity are worse than zero. But I continued - tubed the baby, did compressions, put in a central line and gave epi, put in a chest tube etc. Somehow got him back. Almost ended up doing a pericardiocentesis later. Probably all of that for the sake of the family? The baby died later that night. On the face of it, we all kind of knew it was futile. But it's hard to lose both your wife and your unborn child in the same day. No one really would have blamed me if I had just wrapped up the baby and given him to dad to hold - and maybe that would have been the right answer? I am not sure. Would that have been kinder? I don't know what the right answer is.

...coding a 23 weeker... that’s... oh geez... I don’t even have the words. Is it ethical to code something that premature knowing the outcome is death or severe disability?

 

[SurfingDoctor]

I can speak from the NICU/Peds perspective (I'm a NICU fellow)...I think sometimes we do futile care for the sake of the parents. Not too long ago, I got called to the ED because parents got into a car accident and the mother died while pregnant (essentially died on the way to the hospital, they were doing compressions as they were wheeling her in). Dad was unharmed. It was initially unclear gestation, but then mom was 23 weeks per dad. OBs did a C/S in the ED while mom was getting resuscitated...I get a baby on the warmer. Definitely weighed less than 1lb (I initially estimated the weight between 350g-400g for code med purposes), and the baby looked younger than 23 weeks by appearance with a very barely perceptible heart rate.

Dad wanted everything. At this point, the chance of survival were almost zero, and the chance of survival without severe morbidity are worse than zero. But I continued - tubed the baby, did compressions, put in a central line and gave epi, put in a chest tube etc. Somehow got him back. Almost ended up doing a pericardiocentesis later. Probably all of that for the sake of the family? The baby died later that night. On the face of it, we all kind of knew it was futile. But it's hard to lose both your wife and your unborn child in the same day. No one really would have blamed me if I had just wrapped up the baby and given him to dad to hold - and maybe that would have been the right answer? I am not sure. Would that have been kinder? I don't know what the right answer is.

I’m not sure who it would have been kinder too, but in all honesty, the baby probably didn’t feel anything.

 

[MEN2C]

...coding a 23 weeker... that’s... oh geez... I don’t even have the words. Is it ethical to code something that premature knowing the outcome is death or severe disability?

Some places are now resuscitating at 22 weeks, but that is still controversial. Generally, most places will resuscitate at 23 weeks if parents want us to. In an ideal scenario (controlled birth, singleton pregnancy, good weight, mom gets steroids prior to birth etc), the outcomes are still bad but you can see some successes. This was obviously far from ideal scenario.

I had to defend my decision to the attending later, but in the end, he said he would have done the same thing. I think some of the older attendings might not have resuscitated (in fact I know one did not in a similar situation a while ago). So probably experience (and hopefully associated wisdom) plays a role in how comfortable someone is in refusing to give “futile” care.

 

[Hamhock]

...coding a 23 weeker... that’s... oh geez... I don’t even have the words. Is it ethical to code something that premature knowing the outcome is death or severe disability?

Death isn't a bad outcome.

And dead people, of any age, don't care about "being coded".

Resuscitating to severe disability is my only fear -- otherwise, I have no problem "flogging" a dead person if it helps the staff, family, or trainee education.

In contrast, I have severely regretted placing a conscious person on mechanical ventilation. Ugh.

HH

 

[MEN2C]

How do you guys in the adult world balance family wishes vs resuscitating to severe disability? It’s a constant topic of conversation in the peds arena. Sometimes we can be very sure that this baby will never walk, talk, eat or do anything on their own for the rest of their lives - will forever be vent dependent....but family wants everything.

 

[WheezyBaby]

How do you guys in the adult world balance family wishes vs resuscitating to severe disability? It’s a constant topic of conversation in the peds arena. Sometimes we can be very sure that this baby will never walk, talk, eat or do anything on their own for the rest of their lives - will forever be vent dependent....but family wants everything.

Educating and advocating as best you can but following the family's wishes to attempt resusc if that's what it comes to

 

[MEN2C]

Should we, as medical professionals, get any say in what level of permanent disability is acceptable? I’ve had a baby who essentially only had a brain stem - and not all of it at that- everything above the brain stem was basically water). And parents wanted everything. Trach. G tube. The works. Should we be obligated to do everything?

 

[MoMoGesiologist]

Should we, as medical professionals, get any say in what level of permanent disability is acceptable? I’ve had a baby who essentially only had a brain stem - and not all of it at that- everything above the brain stem was basically water). And parents wanted everything. Trach. G tube. The works. Should we be obligated to do everything?

they should be obligated to pay for everything

 

[Hamhock]

Should we be obligated to do everything?

We are not obligated to do everything. I don't just mean theoretically. You not are obligated to do everything (especially non-emergent 'everythings' when other physicians are available) theoretically or practically.

It has been rare in my still young career, but I have declined procedures, medicines, and even transfers (typically to families, but also declined directly to patients). I have never prevented them from asking other physicians, but I have refused (directly and indirectly, by not offering).

It is preferable to help families understand and agree with your viewpoint (and that is all it is), but sometimes I must say I feel strongly that a treatment is unethical. I excuse myself. I offer to connect them with other physicians. [Think about these issues and your own ethics before being in this situation.]

The few times I have declined to participate in something unethical -- and started to connect families with other physicians -- the families have quickly changed course.

HH

 

[Hamhock]

they should be obligated to pay for everything

Is the cost to "the system" really what holds you back?

HH

 

[ShockIndex]

Should we, as medical professionals, get any say in what level of permanent disability is acceptable? I’ve had a baby who essentially only had a brain stem - and not all of it at that- everything above the brain stem was basically water). And parents wanted everything. Trach. G tube. The works. Should we be obligated to do everything?

I don’t offer treatments that are medically unnecessary or futile. Sue me. Where this becomes an issue is CPR and intubation. I generally don’t offer CPR and rarely offer intubation to the terminally ill. I don’t offer or perform CPR on profoundly demented. The rare exception for intubation is when there is a single organ system acutely failing and intubation has a clear endpoint such as massive hemoptysis.

Where it gets difficult is in young patients who had care escalated by a series of different attendings to the point of futility. I can think of one guy who sat on V-V ECMO for several weeks with obliterated lungs from necrotizing PNA thanks to IVDA. His oxygenator was replaced once when it clotted. The family was finally told that it would not get replaced again despite their objections. Another guy was 25 years old with a destination LVAD for 5 years with multiple complications thanks to a healthy and ongoing cocaine habit. He was told that his perc lead / motor was about to fail and he was not getting another after showing up to clinic and the ED drunk/high on a weakly basis.

Some of my favorite attendings are the ones who don’t offer the world and force patients/families to face reality.

 

[deleted171991]

How do you guys in the adult world balance family wishes vs resuscitating to severe disability? It’s a constant topic of conversation in the peds arena. Sometimes we can be very sure that this baby will never walk, talk, eat or do anything on their own for the rest of their lives - will forever be vent dependent....but family wants everything.

Unless there are clear provisions in the patient's living will, or s/he has expressed strong wishes while still competent (and there is no designated healthcare proxy to overrule them), the spouse's word (or the word of whoever the law designates) is the patient's word. I try to keep the families happy, but if the patient has clear, well-documented, wishes, and nobody to legally overrule them, I tell them that my hands are tied. E.g. if the patient made himself DNR and it's well-documented, the patient is DNR, regardless what the family wants.

Peds is a different story, much more complicated, but even there you have the legal system (if there is time). Still, we ain't the UK and other socialized medicine nations, which will promptly stop futile care.

 

[Nephro critical care]

I recently denied HD to a pts family. Terrible type 1 aortic dissection with pericardial tamponade and BP of 70 maxed on pressors. Wheelchair bound. 5 cardiothoracic surgeons at different hospitals said the dissection was inoperable. Family still wanted hemodialysis.
Didnt make sense to put HD catheter for CRRT.

 

[Siggy]

It depends on the circumstances. I rarely declare people futile (or the wording I've heard and liked, "aggressive care is medically ineffective and potentially inappropriate), but I have no problem doing so when I feel appropriate. One thing to keep in mind is that while you don't have to code everyone (albeit you'll often get a lot of push back), there's also no rule on how long you have to code someone. Slow codes (medical theater) is wrong. There's nothing unethical about a fast code (calling after 2-4 minutes) when appropriate.

 

[chocomorsel]

I can speak from the NICU/Peds perspective (I'm a NICU fellow)...I think sometimes we do futile care for the sake of the parents. Not too long ago, I got called to the ED because parents got into a car accident and the mother died while pregnant (essentially died on the way to the hospital, they were doing compressions as they were wheeling her in). Dad was unharmed. It was initially unclear gestation, but then mom was 23 weeks per dad. OBs did a C/S in the ED while mom was getting resuscitated...I get a baby on the warmer. Definitely weighed less than 1lb (I initially estimated the weight between 350g-400g for code med purposes), and the baby looked younger than 23 weeks by appearance with a very barely perceptible heart rate.

Dad wanted everything. At this point, the chance of survival were almost zero, and the chance of survival without severe morbidity are worse than zero. But I continued - tubed the baby, did compressions, put in a central line and gave epi, put in a chest tube etc. Somehow got him back. Ended up needing lots of blood and other product, pressors etc. Almost ended up doing a pericardiocentesis later. Probably all of that for the sake of the family? The baby died later that night. On the face of it, we all kind of knew it was futile. But it's hard to lose both your wife and your unborn child in the same day. No one really would have blamed me if I had just wrapped up the baby and given him to dad to hold - and maybe that would have been the right answer? I am not sure. Would that have been kinder? I don't know what the right answer is.

I wonder how a country with socialized healthcare would have done it.
@Newtwo, care to comment?

 

[Radetzky]

I wonder how a country with socialized healthcare would have done it.
@Newtwo, care to comment?

In the public healthcare system I work in... its very unlikely anyone would have attempted resuscitation.

 

[chocomorsel]

In the public healthcare system I work in... its very unlikely anyone would have attempted resuscitation.

I would like to work in one of those systems someday.

 

[Radetzky]

I would like to work in one of those systems someday.

It would take a massive culture change. People here accept that once they get to a certain age they’ve “had a good innings” and once you sit down and explain (to them or families) what an extended critical illness involves most of them are horrified and don’t want that.

I feel like that’s a completely different cultural attitude to the States.

 

[MoMoGesiologist]

It would take a massive culture change. People here accept that once they get to a certain age they’ve “had a good innings” and once you sit down and explain (to them or families) what an extended critical illness involves most of them are horrified and don’t want that.

I feel like that’s a completely different cultural attitude to the States.

In the US we want everything done at any cost (as long as someone else is paying for it). Here, we are pro-life!

 

[Nephro critical care]

I am not sure why we as doctors do so much aggressive inappropriate csre when we wouldnt want it for ourselves. If I am 85 and have advanced dementia I dont want a feeding tube ; if I go in a persistent vegetative state I sure dont want a trach ; if i have metastatic cancer With zero quality of life I sure dont want 4th line chemo I just want my morphine gtt.
But we have no problems as doctors doing inappropriate stuff to pts.

 

[chocomorsel]

I am not sure why we as doctors do so much aggressive inappropriate csre when we wouldnt want it for ourselves. If I am 85 and have advanced dementia I dont want a feeding tube ; if I go in a persistent vegetative state I sure dont want a trach ; if i have metastatic cancer With zero quality of life I sure dont want 4th line chemo I just want my morphine gtt.
But we have no problems as doctors doing inappropriate stuff to pts.

It’s our damn right! This is America!!! I want what I want, and I want it now. Especially when I don’t have to pay for it.

 

[chessknt]

I am not sure why we as doctors do so much aggressive inappropriate csre when we wouldnt want it for ourselves. If I am 85 and have advanced dementia I dont want a feeding tube ; if I go in a persistent vegetative state I sure dont want a trach ; if i have metastatic cancer With zero quality of life I sure dont want 4th line chemo I just want my morphine gtt.
But we have no problems as doctors doing inappropriate stuff to pts.

Have you no faith?

John 10:27–28: My sheep hear my voice, and I know them, and they follow me: and I give unto them ECMO; and they shall never perish.

 

[deleted697535]

Very hard to say as its so provider dependent. Plus its peds which i know less than 0 about

Ive seen insane mother****ing **** done to old people if thats of any use. Of course the family 'ask' for it.

 

[deleted697535]

I am not sure why we as doctors do so much aggressive inappropriate csre when we wouldnt want it for ourselves. If I am 85 and have advanced dementia I dont want a feeding tube ; if I go in a persistent vegetative state I sure dont want a trach ; if i have metastatic cancer With zero quality of life I sure dont want 4th line chemo I just want my morphine gtt.
But we have no problems as doctors doing inappropriate stuff to pts.

Fear. Ive seen all of the above done, many times.
Plus you can bill for it

And usually those that order it, dont do the procedure nor take any of the risk, so its not on their monthly slate.
The amount of times ive been asked to do some stupid **** to 'unify the disgnosis' is beyond belief.

 

[MEN2C]

My primary goal for my death is to do my best to not be in a hospital when it happens.

 

[chocomorsel]

Very hard to say as its so provider dependent. Plus its peds which i know less than 0 about

Ive seen insane mother****ing **** done to old people if thats of any use. Of course the family 'ask' for it.

Is the word “provider” also used commonly outside of the US? Say it isn’t so.

 

[jthedestroyr]

I cross out provider and write physician still lol!

@choco they changed the forms now to be more "inclusive" where you and I did fellowship. I think that whole hospital system is going to be nursing run system in another 20 years or less.