We've gone crazy

[Radetzky]

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PubMed® comprises more than 39 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full text content from PubMed Central and publisher web sites.

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You wouldn't inflict this kind of torture on your dog. How did anyone think this was acceptable let alone worthy of a case report?

The worst thing is the conclusions of the study are all about tracheal toilet and checking cuff pressure, not dont intubate 95 year olds for two years!

 

[SurfingDoctor]

PubMed

PubMed® comprises more than 39 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full text content from PubMed Central and publisher web sites.

www.ncbi.nlm.nih.gov

You wouldn't inflict this kind of torture on your dog. How did anyone think this was acceptable let alone worthy of a case report?

The worst thing is the conclusions of the study are all about tracheal toilet and checking cuff pressure, not dont intubate 95 year olds for two years!

It’s China. Maybe they were just curious...

I do like how someone thought “Hey, let’s write this s—t up!”

 

[lymphocyte]

"Conclusion: During prolonged ETI, more attention should focus on airway humidification, proper cuff pressure and optimal time for tube exchange in order to avoid severe complications."

Optimal time for tube exchange.

Their first ETT change was at 450 days.

 

[deleted171991]

Just another proof that families should not drive medical care.

 

[DrGasPasser]

Just another proof that families should not drive medical care.

Probably the only redeeming feature of single payer is having a rationing committee serve as an objective 3rd party to tell the family (and far many doctors) “no.”

 

[Radetzky]

Probably the only redeeming feature of single payer is having a rationing committee serve as an objective 3rd party to tell the family (and far many doctors) “no.”

I live in a single payer country. There's no such thing as rationing committees. It is doctors that say no to futile care.

 

[lymphocyte]

My mentor has a beautiful way of doing end of life discussions, which is strongly centred around "goals of care." "Where are you up to in life, and where are you going"? He makes it very clear that the family's job IS NOT to decide on the particulars of medical treatment -- that's the expertise we offer as doctors. Family's offer a different but equally valuable kind of expertise, which is what patient's might want their life to look like at the very limit of what they'd find acceptable. He almost never asks the question, "do you want CPR"? but rather something along the lines of: "based on what you've said, it sounds like Mr Smith would not want to be in a high-level nursing home or neurologically devastated. Based on that, it would be inappropriate to do things like x,y, or z but here's what we can do to give him the best shot possible." He gets excellent outcomes from these discussions and family's love him.

I'm sure this is all preaching to the choir, but I'm very curious to hear how everybody approaches end of life discussion and making the transition to full palliation of symptoms?

 

[lymphocyte]

I live in a single payer country. There's no such thing as rationing committees. It is doctors that say no to futile care.

Living in the same country as you, I almost wish it were a little harder to withdraw care. I've seen some truly egregious cases going the other direction. But I'm also VERY mindful of the slippery slope that is taking even the slightest bit of clinical decision-making away from front-line clinicians. I'm not sure where the balance lies.

 

[chessknt]

My mentor has a beautiful way of doing end of life discussions, which is strongly centred around "goals of care." "Where are you up to in life, and where are you going"? He makes it very clear that the family's job IS NOT to decide on the particulars of medical treatment -- that's the expertise we offer as doctors. Family's offer a different but equally valuable kind of expertise, which is what patient's might want their life to look like at the very limit of what they'd find acceptable. He almost never asks the question, "do you want CPR"? but rather something along the lines of: "based on what you've said, it sounds like Mr Smith would not want to be in a high-level nursing home or neurologically devastated. Based on that, it would be inappropriate to do things like x,y, or z but here's what we can do to give him the best shot possible." He gets excellent outcomes from these discussions and family's love him.

I'm sure this is all preaching to the choir, but I'm very curious to hear how everybody approaches end of life discussion and making the transition to full palliation of symptoms?

Ive found this is extremely dependent on environment. If you are in a tertiary/quartenary center and taking care of someone who was transferred to get 'the best' then trying to get a family to put limits on care in an obviously doomed patient is nigh impossible without several weeks of no progress unless you unilaterally come down and say we won't be offering cpr/crrt etc.

In a community hospital it is much easier and the patient values discussion tends to go much better.

 

[DrGasPasser]

I live in a single payer country. There's no such thing as rationing committees. It is doctors that say no to futile care.

Tell that to the Brits or Canadians. When the NHS ran low on funds, a moratorium was placed on elective surgeries for smokers and the obese to stretch the budget. In Canada, there are close to 1 million people waiting for procedures - 4 weeks for a CT; 10 weeks for a MRI.

In a country of 350 million like the US, there is absolutely no way to provide universal coverage through a single payer without rationing. While they may not go by the name rationing committee, you bet your ass there will be some non-physician regulatory body that determines what gets funded and who gets to wait.

As for addressing end of life issues, it’s simple: doctors need to stop offering futile treatments like CPR, intubation, etc. to patients with terminal illnesses. Simply tell the family that the patient is dying and ask them if they want to be by the patient’s side as they die. Discussing “code status” regarding a severely demented octogenarian is *****ic.

 

[Radetzky]

Tell that to the Brits or Canadians. When the NHS ran low on funds, a moratorium was placed on elective surgeries for smokers and the obese to stretch the budget. In Canada, there are close to 1 million people waiting for procedures - 4 weeks for a CT; 10 weeks for a MRI.

In a country of 350 million like the US, there is absolutely no way to provide universal coverage through a single payer without rationing. While they may not go by the name rationing committee, you bet your ass there will be some non-physician regulatory body that determines what gets funded and who gets to wait.

As for addressing end of life issues, it’s simple: doctors need to stop offering futile treatments like CPR, intubation, etc. to patients with terminal illnesses. Simply tell the family that the patient is dying and ask them if they want to be by the patient’s side as they die. Discussing “code status” regarding a severely demented octogenarian is *****ic.

For sure, I was talking more about decisions made with patients admitted acutely to hospital.

 

[lymphocyte]

When the NHS ran low on funds, a moratorium was placed on elective surgeries for smokers and the obese to stretch the budget.

The UK does NOT have a single-payer system, and any country that charges money for healthcare "rations." I would argue that among developed countries, the US has the most amount of healthcare that is rationed by pecuniary rather than medical concerns.

And you're talking about free elective surgeries where people are actively supported in losing weight or quitting smoking -- many patients who can't meet these goals are still permitted to go on to have their free elective surgeries. If your BMI is 50, and you're an active smoker, maybe a (free) elective hernia repair can wait. Did I mention free and elective?

As for addressing end of life issues, it’s simple

I've literally never heard this phrase before.

 

[DrGasPasser]

It’s hard to argue that the US has the most amount of pecuniary rationing when we consume the most per capita healthcare resources in the world. Hell, our “impoverished” (a relative term to those living in other parts of the world), consume more resources than their counterparts in Europe.

How does health spending in the U.S. compare to other countries? - Peterson-Kaiser Health System Tracker

Addressing end of life issues became very simple for me when I overcame the anxiety associated telling patients and family members that they were dying. I’ve literally told hundreds (if not thousands) of patients and family that death was inevitable and we were going to keep them comfortable during their death. I can think of maybe 4 or 5 instances where the family demanded a second opinion. Contrast that with consultants and colleagues who insist that patients with devastating illnesses could survive (as if their are no fates worse than death) and want to have a detailed (and confusing to patients) “code status” discussion about CPR, intubation, etc. for whatever reason (30 days post-surgery seems to be a common reason in our surgical ICU). Bottom line, the patients and families are rarely the problem...