Tuesday, February 6, 2007

Setting Limits in End of Life Care BMJ; Crackberry

The British Medical Journal published a very good, well-written overview article on Defining Limits in Care of Terminally Ill Patients by Dr. Ursula Braun and her colleagues. It takes a Problem-Based Learning approach to a common medical scenario: the crashing patient with inconsistent documentation of their wishes and a family with sub-optimal communication. Using this case, Dr. Braun covers the best approaches to building a consensus. Some of the key points made include:

...after acknowledging the situation’s difficulty, (doctors should) present their expert opinions and not shy away from making recommendations because of a misplaced fear of upsetting the patient or surrogate.
I frequently instruct medical students, residents and fellows that pass through my hospice agency that patient autonomy does not mean our professional opinion is unimportant. When it comes to prescribing cholesterol medications, we don't always stop to say, "Now what do you think would be best?" Physicians will say, "Your cholesterol is high, diet and exercise did not work as we hoped, and now you should be on Brand X to decrease your risk of cardiovascular complications. Here is your script." Here professional opinion weighs heavily on the situation.

In an effort to seem completely objective (especially in life and death/EOL/terminal cases) we risk abandoning our patients and their families by not offering a suggestion for best medical course that fits with the patients expressed wishes (if known). The "If it were my mother" question always seemed slightly bogus to me, although it does raise a good point. How would a physician decide to care for their loved one? My standard reply to families or patients is that I would find out what was important to her, weigh the risks and benefits of the medical options given and choose the one that fit best with her goals. So on one hand it seems like a cop out because I won't say "I would put a PEG in my mom." But I do try and reflect the words that the patient or family have used to frame the decision. "Well, given what you said about your mother being fiercely independent and wanting to ride her Harley to South Dakota every year, we should/should not do XYZ"

Also this point was great. I need to make a plaque out of this sentence.
Curative and palliative care should not be dichotomous.
One question I had was this sentence:
Additionally, in some US states patients can opt for do not resuscitate orders out of hospital.
Are there really states where you cannot get a Out of Hospital DNR?

One minor beef I had (more a style point if anything):
For example, when discussing cardiopulmonary resuscitation, it is important to explain that ribs may be broken, burns can occur, success is inversely proportional to length of resuscitation, and the likelihood of returning to the former level of functioning may be small.
I agree with most of this sentence but, I really try not to highlight all the bad things (broken ribs, burns, etc.) because it seems a little bit like a scare tactic. And I have had some patients and families use the excuse that if they die, it wouldn't matter anyway. Instead I prefer to bring up the time of death situation and demonstrate we have two main options:

1) Look at the patient, see that the heart has stopped beating or had a fatal rhythm or that the lungs have stopped breathing and say, "Now we have something to fix." Then the scene becomes one of urgency, chaos and strangers trying to fix things.


2)We can look at the patient, understand all they have been through recently and in their life, realize this is a time when the body may say, "I can't be fixed." And instead of emergency, strangers and chaos, we can work on peace, family and comfort. This may be one of the most important times in this person's life.

Most people understand these differences, and brings up similar issues without getting gruesome or gory.

One other small point that was not fully addressed is the often difficult case of differing physician opinions and communications with families.

Overall great article. I would recommend it as a great overview, introduction article to principles of palliative care and patient-physician communication.
And in typical BMJ fashion they have some cheeky humor at the bottom of the last page of the article about using a CAGE like questionnaire for Blackberry users called the SHAM Screening Test. I have a Blackberry, but I am 0 for 4 on the questions. Phew!

• Do you get annoyed if you are asked to Stop using your hand held device?
• Do you take your hand held device on Holiday with you?
• Do you get Anxious if you cannot find your hand held device?
• Do you ever Misperceive a sound as the ring tone or call sign of your hand held device?

Kudos to Mark Taylor for the submission to BMJ.

(Thanks to Tom Quinn for the idea for submission.)

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