Stupid ethics class makes me want to vomit

[Law2Doc]

---

Members do not see this ad.

Well, sure, if one didn't already know it's important to have the patient provide informed consent. 99% of the stuff my profs go over in classes like this is either common sense or stuff one can and will pick up on the wards anyway,

FWIW, having helped grade quite a few ethics tests at other professional schools, I can assure you that a lot of what you'd think is "common sense" unfortunately isn't as common as you'd like to think. It's probably the minority of the class that invariably gravitates toward the right ethical answer on some of the more complicated issues.
Law, accounting and business schools all have far more formal "ethics" classes than medicine (usually semester-long, essay laden endeavors), so we are getting off easy with whatever smattering of lectures they give us in med school.
I do agree that the ethics classes I have seen seem to be haphazard afterthoughts rather than well organized classes. There is actually some value in ethics classes that are done well. But FWIW, even where it is done well, people still seem to gripe.

 

[Quix]

But FWIW, even where it is done well, people still seem to gripe.

QFT.

Now, before anyone else chooses to sling insults instead of analysis, I amended my previous comments, admitting I made a pretty bad generalization about PB's preparedness to handle complex clinical cases. I don't know him nor his experience, so I don't feel comfortable making that claim.

Regardless, the analysis offered is not the approach taken by the consult team, which was composed of clinicians (nurses and doctors) with significant experience (decades) working with families who were conflicted about what to do with their loved one along with me (as a graduate student at the time). We considered and ultimately disagreed with the solution offered by PB, as it would have had a bad outcome for the family involved (it only addresses the medical issues, not the concomitant psychosocial and interpersonal issues addressed in a volatile family situation).

So, if you want to disagree with me, fine, feel free, but please be courteous enough to include something other than ad hominems.

 

[akpete]

^^Lamest and most overplayed statement that can be written on SDN. 👎 Yes, what someone writes on an anonymous internet message board is definitely the best predictor of beside manner in medical student.

👍 I was about to type the exact same thing until I scrolled down a bit farther. So sickening.

 

[8744]

Panda Bear-

I'm sorry to tell you that this is a legit case; there is nothing bogus about it. This was one of the first cases I was involved in in clinical consultation. The patient was real, the family was real, and the conflict was real. If you think the solution is straight-forward, you really are unprepared for clinical ethics.

Tic- No she didn't have an AD or PoA. That was part of the reason why the consult was called.

First of all, and this will come as a shock to you, most physicians look at "ethics consults" as something of a cop-out unless it is to iron out some medico-legal issue which has nothing to do with the ethics of the case. I don't need a committee to tell me what is right and wrong and even as a PGY-2 I am confident enough to tell a family or a patient what I think, what I think they should do, and what I would do if the patient were my father or mother. This is the essence of not being a legalistic wuss and stepping up to the plate, so to speak, when it is time to act like a physician. God knows there are few benefits to being a resident. One of them, however, is that as a physician you can speak your mind and give your opinion without fear of censure.

I have done a total of six critical care months as a resident and I have yet to invoke the ethics committee or see anyone else doing it. Very few cases need that kind of scrutiny, not even the one you quoted which, real or not, is not really that complicated. All that is required is for the senior physician on the case to correct the erroneous perceptions and false choices presented by a confused medical staff to an equally confused family.

I certainly don't need a group of braying, non-medical civilians with PhDs in empathy telling me what to do or say. I get much better input from the ICU nurses who really know what's going on.

Your extensive and legitimately impressive credentials aside, I would ask you to step out of any discussion with the critically ill patient or the family because you have nothing legitimate to offer. Most SDN regulars know that I am not exactly in love with the medical profession and don't think that doctors are some kind of god but there are times when a doctor has got to act like a doctor and push the amateurs, that is, those without clinical responsibility for the patient, out of the room. That's why the charge nurse and the nurse following the patient are always invited to the family meeting.

As to a patient not having advanced directives or a living will....well stop the friggin' presses. This is not a rare event and does not require an automatic ethics consult.

"Unprepared for clinical ethics." Har har. I've at least ten "family meetings" to break bad news or to tell the family that it is time to give it up (which is good news if you think about it) in the last two months.

 

[8744]

But FWIW, even where it is done well, people still seem to gripe.

QFT.

Now, before anyone else chooses to sling insults instead of analysis, I amended my previous comments, admitting I made a pretty bad generalization about PB's preparedness to handle complex clinical cases. I don't know him nor his experience, so I don't feel comfortable making that claim.

Regardless, the analysis offered is not the approach taken by the consult team, which was composed of clinicians (nurses and doctors) with significant experience (decades) working with families who were conflicted about what to do with their loved one along with me (as a graduate student at the time). We considered and ultimately disagreed with the solution offered by PB, as it would have had a bad outcome for the family involved (it only addresses the medical issues, not the concomitant psychosocial and interpersonal issues addressed in a volatile family situation).

So, if you want to disagree with me, fine, feel free, but please be courteous enough to include something other than ad hominems.

The family is not your patient, your patient is.

Again, like most amateurs you are trying to wiggle your way deep, deep into the mind of your patient and their families, a place where you do not belong. Let the family work out their own interpersonal issues. The more volatile the family the more you want to avoid trying to sort 'em out. You just give them the facts, firmly but respectfully state your opinion, and tell them what you think they need to do. Then you give them a period to ask questions which you answer fairly but witout giving in to their bargaining, expectations, or preconceptions, after which you give them time to make up their minds. If you think it's time to pull the plug on granny then say so. if they don't want to then you do what they want until granny eventually codes and you get a little practice in ACLS.

Until such a time as doctors are allowed to decide code status that's all you can do.

I'm always very clear to the families what we're going to be doing to their loved ones to try to bring them back.

 

[Quix]

Again, I'll disagree. Since it seems no one else wants to discuss the case, I'll explain what we did and why.

The patient had plateaued - she wasn't getting and better and she wasn't getting any worse. The treatment staff wasn't sure whether to proceed simply because there was a legitimate question as to whether or not aggressive therapy would return her to her pre-admission baseline. The family had not received conflicting information (a rarity), but they fundamentally disagreed as to what they wanted to do.

The caregiver daughter was absolutely adamant about continuing treatment, up to and including very aggressive measures, basing her position on the third daughter (the one who had had the stroke). In the twenty years since the third daughter had died (it occurs to me that I hadn't made that clear in the initial case presentation (and I will have to amend that before I present it again)), there had been no other information or evidence presented that their mother felt any differently than being a vitalist. The clinically-trained daughter was basing her feeling of what her mother wanted based solely on her impressions of being in the same room with her mother's unconscious body. She had no insights into her mother's wishes aside from simply saying "I don't think she would want it." The brother was essentially useless, he was content to sit and stare at the table while we met with the family.

Our big concern, aside from trying to get some headway into how to proceed, was how to avoid destroying the family. The daughters hadn't spoken for three years after the BKA; the mother's death would likely have produced a huge schism, especially if one felt like she was being ganged-up upon, so our first priority was getting them on the same page. We asked them questions to get them to realize that none of them wanted their mother to die, or had any bad feelings towards her, and would want her to be awake and happy. They all agreed that the only evidence we had pointed to her mother wanting intervention, and they all agreed that if she got worse, they would be willing to come back and sign a DNR.

The way things played out, the mother went south and died two weeks later, but the family was supportive and as of our last contact with them, there was no enmity between them. So part of the issue is autonomy, part of it is family management, and part of it was preserving the family unit. We didn't want a family already dealing with serious illness to start fighting amongst themselves; that simply makes a bad situation worse. If we had tried to push them in a particular direction, at least one of them would have bristled and gotten defensive, at which point any suggestions we would have made would have been fruitless (in fact, this is one of the reason why the consult had been called - previously, an attending had attempted to push them towards forgoing treatment, and while the clinically-trained daughter agreed, the caregiver daughter didn't (quite vociferously, in fact)).

I know there are many docs who feel that ethics consults and committees are (a) the "ethics police" in the hospital, or (b) useless, and they are free to have their opinions, but we actually do prevent quite a few problems. If your hospital does things differently, I'm sure there is a reason. I'm just concerned when someone suggests these cases are easy and solved by simply "correcting" bad information. As I'm sure you know, sometimes people respond to information positively, sometimes negatively, sometimes rationally, and sometimes irrationally. It's tricky waters.

Anyway, we can agree to disagree on this one. I love your blog, btw. I've been putting together a book about my experiences working on a psych floor for two years, and I was reminded of it while reading what you wrote.

 

[8744]

Again, I'll disagree. Since it seems no one else wants to discuss the case, I'll explain what we did and why.

The patient had plateaued - she wasn't getting and better and she wasn't getting any worse. The treatment staff wasn't sure whether to proceed simply because there was a legitimate question as to whether or not aggressive therapy would return her to her pre-admission baseline. The family had not received conflicting information (a rarity), but they fundamentally disagreed as to what they wanted to do.

The caregiver daughter was absolutely adamant about continuing treatment, up to and including very aggressive measures, basing her position on the third daughter (the one who had had the stroke). In the twenty years since the third daughter had died (it occurs to me that I hadn't made that clear in the initial case presentation (and I will have to amend that before I present it again)), there had been no other information or evidence presented that their mother felt any differently than being a vitalist. The clinically-trained daughter was basing her feeling of what her mother wanted based solely on her impressions of being in the same room with her mother's unconscious body. She had no insights into her mother's wishes aside from simply saying "I don't think she would want it." The brother was essentially useless, he was content to sit and stare at the table while we met with the family.

Our big concern, aside from trying to get some headway into how to proceed, was how to avoid destroying the family. The daughters hadn't spoken for three years after the BKA; the mother's death would likely have produced a huge schism, especially if one felt like she was being ganged-up upon, so our first priority was getting them on the same page. We asked them questions to get them to realize that none of them wanted their mother to die, or had any bad feelings towards her, and would want her to be awake and happy. They all agreed that the only evidence we had pointed to her mother wanting intervention, and they all agreed that if she got worse, they would be willing to come back and sign a DNR.

The way things played out, the mother went south and died two weeks later, but the family was supportive and as of our last contact with them, there was no enmity between them. So part of the issue is autonomy, part of it is family management, and part of it was preserving the family unit. We didn't want a family already dealing with serious illness to start fighting amongst themselves; that simply makes a bad situation worse. If we had tried to push them in a particular direction, at least one of them would have bristled and gotten defensive, at which point any suggestions we would have made would have been fruitless (in fact, this is one of the reason why the consult had been called - previously, an attending had attempted to push them towards forgoing treatment, and while the clinically-trained daughter agreed, the caregiver daughter didn't (quite vociferously, in fact)).

I know there are many docs who feel that ethics consults and committees are (a) the "ethics police" in the hospital, or (b) useless, and they are free to have their opinions, but we actually do prevent quite a few problems. If your hospital does things differently, I'm sure there is a reason. I'm just concerned when someone suggests these cases are easy and solved by simply "correcting" bad information. As I'm sure you know, sometimes people respond to information positively, sometimes negatively, sometimes rationally, and sometimes irrationally. It's tricky waters.

Anyway, we can agree to disagree on this one. I love your blog, btw. I've been putting together a book about my experiences working on a psych floor for two years, and I was reminded of it while reading what you wrote.

This is so not your problem or any of your business.

 

[want2beadoc]

Bravo.

 

[Quix]

This is so not your problem or any of your business.

I disagree. First, these kinds of decisions don't exist in a vacuum, so their effects are felt in more than just the physician-patient relationship. From an altruistic perspective, it's helpful when they are going through something difficult. From a self-interest perspective, it helps to avoid concerns about litigation if a family member feels wronged or pushed into a decision. Second, the hospital was religiously-based and community-based, which affected the perception of responsibility. In the twelve consults I was involved in (some yielding continuity of care, some yielding cessation of care), being patient-centered in our approach consistently involved preventing familial strife as much as possible. It just seems like a common-sense thing to me - it's a land-mine we can see, so it makes sense to avoid it.

 

[want2beadoc]

I would like to add that in some way it is a little sick to use a patient as a pawn to mend broken familial relationships. In this case, its turned out ok, but I can see there being huge pitfalls for all parties involved (physicians, family, and patient).

 

[Quix]

I would like to add that in some way it is a little sick to use a patient as a pawn to mend broken familial relationships. In this case, its turned out ok, but I can see there being huge pitfalls for all parties involved (physicians, family, and patient).

That certainly is not the approach we took with this case or any other. The interests of the patient were always front and center; any family issues that were present were simply the result of disagreement over how to take care of the mother. We weren't attempting to correct any other issues that may have been present, we were focussing on a reasonably foreseeable consequence of our actions, and thought it would make sense to act in a manner that didn't aggrevate any other family issues. The picture that was painted of the patient by interviewing her family was one that did not want conflict, especially if it could be reasonably avoided.

 

[78222]

I have nothing to add beyond what Panda Bear has said. It's not your job as a physician to mend their family. It's your job to tell the patient (or whoever is in charge of the patients wellbeing) what the facts, options, and scenarios stemming from these options are. It's not your job to play psychologist. In fact, this is one of the things annoying the hell out of me about these stupid classes. In their drive for "empathy" they are basically telling us to meddle into the lives of our patients.

 

[Quix]

Again, as with PB, we'll just have to disagree on this, as well as on your characterization of how we approached and resolved the problem.

 

[8744]

This is so not your problem or any of your business.

I disagree. First, these kinds of decisions don't exist in a vacuum, so their effects are felt in more than just the physician-patient relationship. From an altruistic perspective, it's helpful when they are going through something difficult. From a self-interest perspective, it helps to avoid concerns about litigation if a family member feels wronged or pushed into a decision. Second, the hospital was religiously-based and community-based, which affected the perception of responsibility. In the twelve consults I was involved in (some yielding continuity of care, some yielding cessation of care), being patient-centered in our approach consistently involved preventing familial strife as much as possible. It just seems like a common-sense thing to me - it's a land-mine we can see, so it makes sense to avoid it.

Aha. There's the friggin' bottom line and the only reason hospitals have ethics committees, that is, fear of litigation.

"Patient Centered." Another phrase that makes me reach for my revolver. We are all "patient centered," buddy.

Seriously, do you really talk like that? You sound like the typical hospital bureaucrat.

 

[OncoCaP]

Aha. There's the friggin' bottom line and the only reason hospitals have ethics committees, that is, fear of litigation.

"Patient Centered." Another phrase that makes me reach for my revolver. We are all "patient centered," buddy.

Seriously, do you really talk like that? You sound like the typical hospital bureaucrat.

Errr. Panda Bear: As you can tell, he really does talk like that and you aren't going change it, so do you really need to kick the ... out of him for it? This is getting a little crazy. Peace. (By the way, nice blog).

 

[crazy_cavalier]

The family is not your patient, your patient is.

Again, like most amateurs you are trying to wiggle your way deep, deep into the mind of your patient and their families, a place where you do not belong. Let the family work out their own interpersonal issues. The more volatile the family the more you want to avoid trying to sort 'em out. You just give them the facts, firmly but respectfully state your opinion, and tell them what you think they need to do. Then you give them a period to ask questions which you answer fairly but witout giving in to their bargaining, expectations, or preconceptions, after which you give them time to make up their minds. If you think it's time to pull the plug on granny then say so. if they don't want to then you do what they want until granny eventually codes and you get a little practice in ACLS.

Until such a time as doctors are allowed to decide code status that's all you can do.

I'm always very clear to the families what we're going to be doing to their loved ones to try to bring them back.

PBear gives out some quality pearls of wisdom, as usual 👍 👍

If these doctoring classes were taught by him, I'd definitely be taking notes and would feel that they were worthwhile.

 

[8744]

Errr. Panda Bear: As you can tell, he really does talk like that and you aren't going change it, so do you really need to kick the ... out of him for it? This is getting a little crazy. Peace. (By the way, nice blog).

Yes. It is that kind of mealy-mouthed jargon that makes it impossible to say anything of value. It's a cop-out, a way to dodge responsibilty by hiding behind complex legalisms.

Plain simple speech and writing are better. I'm as educated as anybody here, probably more as a matter of fact, and "better read" but I don't see the need to talk like a friggin' lawyer.

 

[pagemmapants]

Why don't people like P-Bear go into academic medicine, damnit?

 

[janedoe4]

I have nothing to add beyond what Panda Bear has said. It's not your job as a physician to mend their family.

Do you think it might be your job, or at least a sensible thing to do, to not further destroy their family? Sensible from a self-interested perspective (avoiding litigation, etc.), and to avoid their conflict harming your patient (however many years Terri Schiavo's family, e.g., spent in court certainly didn't do her any favors and--assuming she didn't want to live in that condition, didn't want the kind of attention she got, etc.--I might say harmed her) And say you're right and it's not your job as the physician--might it be someone else's job (social work, ethics consultant, whatever)? In which case it might be nice to be able to identify situations where those people are called for.

That said (and back to the original topic), I have no trouble believing ethics is poorly taught in many places and made more annoying/useless than it ought to be.

 

[Quix]

PB-

(1) No, I don't "talk this way" when working with patients; when we are discussing cases and theory, however, it seems appropriate. Being "patient centered" means just that - there is nothing more important to us during a consult than taking care of the patient, whether that means treatment and outcome or psych management. I have no doubts that you are patient-centered, but when people start making accusations like "using the patient as a pawn" or "trying to fix a broken family", what is wrong with reminding people that their impression of the event may have nothing to do with what really happened. People are judging me (as well as clinicians with more experience than anyone here of essentially unprofessional conduct), with no appreciation of the case, what went on during it, details that were omitted because of confidentiality, etc., which is asinine.

(2) Exactly why are you so overtly hostile? You have taken every opportunity you can to belittle people, and while I can understand that you get passionate about what you do and have strong opinions on the matter, I don't see exactly how that justifies abusive language. I honestly don't care if we continue this discussion, as you will clearly continue to do things as you see fit (as will I) but what's the point of discussing this if we can't be civil? I'm more than happy to discuss ethics problems here and make the case why it's important in clinical education, but disagreement about cases does not require hostility.

Your adamance that other issues beyond patient care are irrelevant or outside the scope of the consult concerns me, as I disagree with it on both the level of principle and practice. Ethics consults are not simply about avoiding legal liability - that was *one* possible outcome that we sought to avoid. Harping on that doesn't "prove" your point, I only brought it up to demonstrate that in addition to the philosophical and psychological justifications for action, if one wanted to explore pure self-interest, motive existed there, too.

 

[Gimlet]

PB-

(1) No, I don't "talk this way" when working with patients; when we are discussing cases and theory, however, it seems appropriate. Being "patient centered" means just that - there is nothing more important to us during a consult than taking care of the patient, whether that means treatment and outcome or psych management. I have no doubts that you are patient-centered, but when people start making accusations like "using the patient as a pawn" or "trying to fix a broken family", what is wrong with reminding people that their impression of the event may have nothing to do with what really happened. People are judging me (as well as clinicians with more experience than anyone here of essentially unprofessional conduct), with no appreciation of the case, what went on during it, details that were omitted because of confidentiality, etc., which is asinine.

(2) Exactly why are you so overtly hostile? You have taken every opportunity you can to belittle people, and while I can understand that you get passionate about what you do and have strong opinions on the matter, I don't see exactly how that justifies abusive language. I honestly don't care if we continue this discussion, as you will clearly continue to do things as you see fit (as will I) but what's the point of discussing this if we can't be civil? I'm more than happy to discuss ethics problems here and make the case why it's important in clinical education, but disagreement about cases does not require hostility.

Your adamance that other issues beyond patient care are irrelevant or outside the scope of the consult concerns me, as I disagree with it on both the level of principle and practice. Ethics consults are not simply about avoiding legal liability - that was *one* possible outcome that we sought to avoid. Harping on that doesn't "prove" your point, I only brought it up to demonstrate that in addition to the philosophical and psychological justifications for action, if one wanted to explore pure self-interest, motive existed there, too.

Side note: I just think it's interesting that your avatar is of a character who is essentially the antithesis of what you are preaching here. 😛

 

[crazy_cavalier]

Side note: I just think it's interesting that your avatar is of a character who is essentially the antithesis of what you are preaching here. 😛

The phrase under his screen name is also quite ironic 😀

 

[Teee]

this thread is turning too personal... and while i personally hate ethics and philosophy, is there any wonder as to why physician litigations are increasing???

 

[Quix]

Side note: I just think it's interesting that your avatar is of a character who is essentially the antithesis of what you are preaching here. 😛

Best character on the show, bar none.

 

[bjackrian]

Quix,
I just wanted to say thank you for posting that case and the rationale behind it. IMO, if our pre-clincal ethics classes were taught with case studies like the one you provided, it would be a much more worthwhile case. Complex end of life issues, confidentiality issues, etc. are much more difficult than the cut and dried issues they try to present in our classes. Anyway, thanks for posting an interesting case with its outcome. 👍

 

[8744]

PB-

(1) No, I don't "talk this way" when working with patients; when we are discussing cases and theory, however, it seems appropriate. Being "patient centered" means just that - there is nothing more important to us during a consult than taking care of the patient, whether that means treatment and outcome or psych management. I have no doubts that you are patient-centered, but when people start making accusations like "using the patient as a pawn" or "trying to fix a broken family", what is wrong with reminding people that their impression of the event may have nothing to do with what really happened. People are judging me (as well as clinicians with more experience than anyone here of essentially unprofessional conduct), with no appreciation of the case, what went on during it, details that were omitted because of confidentiality, etc., which is asinine.

(2) Exactly why are you so overtly hostile? You have taken every opportunity you can to belittle people, and while I can understand that you get passionate about what you do and have strong opinions on the matter, I don't see exactly how that justifies abusive language. I honestly don't care if we continue this discussion, as you will clearly continue to do things as you see fit (as will I) but what's the point of discussing this if we can't be civil? I'm more than happy to discuss ethics problems here and make the case why it's important in clinical education, but disagreement about cases does not require hostility.

Your adamance that other issues beyond patient care are irrelevant or outside the scope of the consult concerns me, as I disagree with it on both the level of principle and practice. Ethics consults are not simply about avoiding legal liability - that was *one* possible outcome that we sought to avoid. Harping on that doesn't "prove" your point, I only brought it up to demonstrate that in addition to the philosophical and psychological justifications for action, if one wanted to explore pure self-interest, motive existed there, too.

How am I hostile? You make some statements, I tell you how you are wrong. That's not hostility.

 

[berkshiredoc]

I hope you are being confrontational for fun and don't truly believe everything you are saying...One of the major function of ethics classes in med school is to help MD's understand exactly which aspects of a patient's care REALLY ARE medical decisions as opposed to ethical/spiritual/philosophical ones. In your example above, you speak of "civilians" interfering with your MD decisions. Buddy, in Quix's example, there was no clear medical decision to be made unless it was felt that treatment was "medically futile" ( and we have clear guidelines for what that means)...in which case the physician needs to state so clearly and quickly, albeit compassionately, no matter what the family's feelings. Deciding what quality of life in the outcome justifies continued treatment IS NOT a medical decision, and I hate to break it to you, but the SICU janitor's opinion on this question is no more or less valid than yours...that's the lesson you need to learn here. You've done 10 family meetings...what an expert!! I probably have done 5,000 in my 38 year career, and I certainly don't feel as "expert" as you! I'm not going to post again on this thread because it is not productive, and because it's making me very depressed!

 

[Quix]

How am I hostile? You make some statements, I tell you how you are wrong. That's not hostility.

Disagreement in itself isn't hostile; characterization as a "bureaucrat", "mealy-mouthed", "amateur", "reaching for your revolver", "braying non-medical civilians", "pushing people like me out of the room", etc. is. Again, I understand that you feel passionately about this, but we can disagree without having to sink to that level.

 

[45408]

I, for one, prefer my mental vacations to be free of the incessant background babbling of pseudo-intellectual masturbation.

🙁 and it's probably mandatory attendance, too.

 

[Quix]

🙁 and it's probably mandatory attendance, too.

Sounds like an undergraduate seminar I had to take on the "Philosophy of Time" (where we asked questions like "Is the past any more real than the future"); now *that* was intellectual masturbation of the finest sort.

 

[8744]

I hope you are being confrontational for fun and don't truly believe everything you are saying...One of the major function of ethics classes in med school is to help MD's understand exactly which aspects of a patient's care REALLY ARE medical decisions as opposed to ethical/spiritual/philosophical ones. In your example above, you speak of "civilians" interfering with your MD decisions. Buddy, in Quix's example, there was no clear medical decision to be made unless it was felt that treatment was "medically futile" ( and we have clear guidelines for what that means)...in which case the physician needs to state so clearly and quickly, albeit compassionately, no matter what the family's feelings. Deciding what quality of life in the outcome justifies continued treatment IS NOT a medical decision, and I hate to break it to you, but the SICU janitor's opinion on this question is no more or less valid than yours...that's the lesson you need to learn here. You've done 10 family meetings...what an expert!! I probably have done 5,000 in my 38 year career, and I certainly don't feel as "expert" as you! I'm not going to post again on this thread because it is not productive, and because it's making me very depressed!

Well, then let's just consult the janitor and have him decide. Problem solved.

 

[8744]

Hey, why not solve all the families problems for them. Let's get the brother into AA, send the sisters to family counseling, and help cousin Bocephus find a new job after he was laid off down at the Jiffy-Lube for stealing air filters. I mean, since we're making it our business, why not go whole hog? Let's really make the hospital full service, transforming it from a place where the sick go for treatment into the hub of a network of free social services.

Let's admit the whole family for inpatient psychiatric counseling.

Look, at the risk of being cruel, the death of a family member, one who is chronically ill I mean, is not an unusual event that needs to be psycho-babbled up. My father died in an ICU and we did not need grief conselors, ethics consultants, or the hospital lawyers to tell us what to do our how to grieve. It is just a fundamental part of life that you will lose family members. Those are the facts of life and need to be told to the patient's family, something that many don't want to do for fear of appearing insensitive and presumably opening themselves up to litigation.

The family needs to come to grips with it on their own. It's just another form of the entiltlement mentality, let's just call it emotional welfare, that a family would expect the hospital to organize their emotional house...and that people expect to make a living doing it.

 

[Quix]

That's not what is being proposed, PB, and this is another example of being overtly hostile towards those with whom you disagree.

 

[78222]

That's not what is being proposed, PB, and this is another example of being overtly hostile towards those with whom you disagree.

My god man. Get rid of that Dr. Cox avatar and quit yer crying

 

[Quix]

So, still nothing constructive to add to the conversation?

 

[78222]

So, still nothing constructive to add to the conversation?

I told you to quit crying like a prepubescent teenager, how isn't that constructive? I know that being nontrad you assume you get to be an uptight asswad who whines about everything but that doesn't really fly with me. I don't care if you have a PhD in bioethics from Harvard because the fact remains that I don't have a lot of respect for the field of ethics (which is just law disguised as being objective).

 

[Quix]

I told you to quit crying like a prepubescent teenager, how isn't that constructive? I know that being nontrad you assume you get to be an uptight asswad who whines about everything but that doesn't really fly with me. I don't care if you have a PhD in bioethics from Harvard because the fact remains that I don't have a lot of respect for the field of ethics (which is just law disguised as being objective).

It couldn't be more clear that you have a low opinion of ethicists; I'm not here to change that.

Second, you are mistaking dispassionate conversation for crying; sorry if I don't get histrionic when someone insists on slinging insults at me on an anonymous message board.

Third, you are not the standard by which I judge my conduct, so I'm not terribly concerned what exactly "flies with you". I know the field, I work clinically, and I know the kinds of situations that arise as a result. I'll keep my own council as to what makes sense.

 

[8744]

It couldn't be more clear that you have a low opinion of ethicists; I'm not here to change that.

Second, you are mistaking dispassionate conversation for crying; sorry if I don't get histrionic when someone insists on slinging insults at me on an anonymous message board.

Third, you are not the standard by which I judge my conduct, so I'm not terribly concerned what exactly "flies with you". I know the field, I work clinically, and I know the kinds of situations that arise as a result. I'll keep my own council as to what makes sense.

Sure, except you'll air your pet theories here and then get irate because we don't slobber all over them.

 

[Quix]

Again with the hostility, and now you're fiating motives on why I am posting here. What makes you think I'm getting irate? Again, this is a discussion on an anonymous message board, and none of us have met IRL, so it's a little difficult to assume one knows what is going on in someone else's head.

 

[Droopy Snoopy]

You just get the family together, tell them what you think, politely tell them to come to grips with reality, and then do what the legal gaurdians decide. If they can't decide then you continue on doing what you're doing. If you feel strongly about it, and you won't usually, you can get a court order to withhold futile care.

Man, you always know when a thread's gotten someone's a$$hole kinked up when it's like 15 post long one day and 85 the next. Panda Bear is stating how it probably goes in reality; it's the best a busy ICU/ER whatever can do day in and day out. I think Quix's version is better, but if the family were stubborn you'd have to default to Panda Bear's version, right? PB's right in that if docs deferred every situation like this to admin, it would foster poor decision-making skills and be terribly inefficient. Just my opinions, you guys both have light-years more clinical experience than I do.

Anyway, I'm glad to see that particular case worked out well for everyone, and all other things being equal I don't see what it hurts to sit down with the family and try to mediate the situation (while you're at it get 'em all to fill out ADs on themselves). Honestly though, Quix, I'd email you an audio file of one of our ethics discussions if I was sure of the copyright footing. You'd laugh and understand where the OP and most of the rest of us are coming from, because they're beyond worthless, nothing like cases like this.

 

[Quix]

I'd be interested in hearing them were it possible; nothing is more frustrating than a class that seems pointless or intentionally simplistic. If people are interested, I'm happy to post other cases on which I've consulted and we can discuss them.

 

[DoctorFunk]

I'd be interested in hearing them were it possible; nothing is more frustrating than a class that seems pointless or intentionally simplistic. If people are interested, I'm happy to post other cases on which I've consulted and we can discuss them.

God, please no. Let me get back to learning the pathogenesis of MIs instead.

 

[Quix]

God, please no. Let me get back to learning the pathogenesis of MIs instead.

😉

 

[Writer1985]

Sure, except you'll air your pet theories here and then get irate because we don't slobber all over them.

Well, this is what we call "transference." It certainly seems like Quix is the dispassionate academic and PBear is waving a stick of bamboo threateningly because someone suggested that in order to get a treatment consensus out of a family, they first have to agree with each other. (Quelle surprise!)

Honestly, though, this is what's fun about ethics. Two parties looking at a case and through argument, trying to decide what course of action is "right."

 

[racerx]

Honestly, though, this is what's fun about ethics. Two parties looking at a case and through argument, trying to decide what course of action is "right."

Yes, because nothing is more fun and stimulating than arguing to see who is the most intellectually superior. 🙄 😴

 

[bjackrian]

I'd be interested in hearing them were it possible; nothing is more frustrating than a class that seems pointless or intentionally simplistic. If people are interested, I'm happy to post other cases on which I've consulted and we can discuss them.

Well, I for one would be interested, though it sounds like not a whole lot of others are.

 

[Ashers]

God, please no. Let me get back to learning the pathogenesis of MIs instead.

You mean you haven't started studying for the med ethics test yet?

I haven't minded some of the med ethics lectures we've had, but some have literally put me to sleep. Horrible. Then the small group discussions where we rehash everything lecture and personally attack people is just adding to the fun.

 

[GoofyDoc]

Do you think it might be your job, or at least a sensible thing to do, to not further destroy their family? Sensible from a self-interested perspective (avoiding litigation, etc.), and to avoid their conflict harming your patient (however many years Terri Schiavo's family, e.g., spent in court certainly didn't do her any favors and--assuming she didn't want to live in that condition, didn't want the kind of attention she got, etc.--I might say harmed her) And say you're right and it's not your job as the physician--might it be someone else's job (social work, ethics consultant, whatever)? In which case it might be nice to be able to identify situations where those people are called for.

Nobody's destroying the family except themselves. We're not supposed to get too personally involved with our patients, let alone their families. Our job in situations like this is to inform them of the prognosis, explain to them all the options and their worth, and give them time to come to an agreement amongst themselves. That alone will take out a good 45 minutes of your schedule. We have nothing to do beyond that except answer any questions they may come up with and to do as they decide. If the family is in disagreement (as it usually happens in 9 cases out of 10), the patient remains full code and you keep on doing what you are doing. Like Panda Bear said, either they will eventually decide to let go, or the patient will crap out and code on you and that's where you get to practice your ACLS. No ethical dilemma at all here. The only time I've seen an ethics consult was on a disputed brain death. This is how it happens in real life, and no I'm not a prick. The patients' families are always thankful of what we do.

 

[8744]

...Ms. A. is an 84 year-old African American woman. She is currently in the ICU and is non-responsive. She has a past medical history significant for multiple cerebral vascular accidents (strokes) resulting in hemiparalysis (an inability to move her left side). She has diabetes mellitus, peripheral vascular disease (very poor circulation), congestive heart failure, severe sepsis (blood poisoning), and her right leg has been amputated below the knee (secondary to a gangrenous wound several years ago). She has been minimally responsive to treatment...

On a somewhat unrelated note, I want to warn you folks that the above is not an uncommon type of case. It is in fact very mundane, something that won't even raise an eyebrow in most ICUs. If you you showed me her chart I'd say, "Ho hum, not another one. Is that Mrs. Smith, Mrs. Green, or the new lady in room 312?"

And we regularly keep people sicker than her (with the exception of the sepsis) going for years, bouncing them from nursing home to ICU and back several times a year in a game of "hot potato."

At the VA, we had patients even sicker than that who were "full code." The combination of COPD, PVD, CHF, CAD, BKA, ESRD, and CVA in one patient was so common that they referred to it as VARF (VA Associated Risk Factors, as in "Patient is an 83 yeal-old veteran with VARF.")

See my blog for how I feel about the the ridiculous efforts we make to salvage people who are technically dead, just not officially TTJ. (Transferred to Jesus) I suppose that is a topic for another thread. I think that most of us will agree that some of the things we do in the ICU are idiotic and almost criminal from an ethical if not an economic point of view.

But I repeat, until such a time as physicians are allowed to decide code status, you pretty much have to do what the family wants except in the rarest of cases. I have never seen or heard of a critical care physician trying to talk a famiily into not pulling the plug.

 

[racerx]

Today, I was reminded of another reason I dislike our ethics small groups. It is like a political indoctrination camp. We get to sit in a small room and have faculty tell us why the U.S. is the evil reason for all that is wrong with the world. In particular, all white male, christian, americans are evil-doers that would take food from the mouths of babies and take health care from everyone the world around. While our brains are then hypnotized, we are told that the way for us to atone for the 'American Sin' is to vote as far left as the ballot will allow us.

I pay tuition to learn how to become a physician, not be politically "converted". I vote for republicans OR democrats based on the candidate's ideas, not some lock-step ideology driven party line vote.

On a brighter note, it's almost over!!!