1)
This past week has had two fairly prominent major media articles focusing on significant end of life issues. In Time Magazine, Dr. Scott Haig (an orthopedic surgeon) writes about the difficulties physicians encounter when contemplating the appropriateness of Do Not Resuscitate (DNR) orders. (Or more appropriately Do Not Attempt Resuscitation, since we cannot promise any guarantees.) Dr. Haig has written a few pieces for Time before, one of which we noticed here at Pallimed about the VAS for pain being inadequate.
In this recent Time article, Dr. Haig reviews the case of an elderly Italian woman (described as spooky, wacky, cute, and vivacious) who broke a hip and required a lot of medical care before she could undergo the procedure. His description of the tricky balance of caring for geriatric patients is very accurate:
"It took a few days, many medicines and quite a few units of packed red cells to get her blood counts up to the point where she could have the hip operation safely. This is a dicey business with the very old. The transfusions put them into heart failure (the heart can't keep up with the fluid overload, which backs up into the lungs), which has to be treated with diuretics, which drop their pressure, which ruins their kidneys, which makes the heart failure worse. Pneumonia, bed sores, blood clots and dementia nip at them too, along with the paralyzing pain of the broken hip, almost from the minute they fall. It's dangerous to let hip fractures go too long pre-op — and somewhat inhumane. Ask anyone who has had one; the operation relieves a terrible pain."The family had requested a DNR for the patient, but there was no clear evidence that she lacked medical decision making capacity, but she was inferred to be 'high-functioning', so maybe it was a language barrier that precluded direct discussion with her. Anyway that is not the point of the article, but an important one for the public in reading this, because it implies doctors and families can make these important medical decisions for' cute old people who have difficulty communicating (for any reason). Not exactly the message that provides trust in the medical community.
A important fact that is skipped over is the conflicting issue of what to do with a DNR order during an operation. In the article it sounds like they did resuscitate her:
"As we worked on the hip, her ancient heart got balky. So they gave her the same drugs and used the same electrical devices they might have used in a code. And it worked."So did they rescind the DNR during surgery and was this done with informed consent. I would be very interested to hear from other health care professionals on their opinion on DNR's in the OR.
If a DNR order is in place, and it will be rescinded during the time in the OR (and for that matter does it extend to the pre-op or PACU?) it is important to have that discussion with the patient/family before that happens. If someone has a cardiopulmonary arrest while undergoing a procedure does that condition change the underlying understanding of the DNR order? Most surgeons and proceduralists would say something to the effect:
"Yes, it does. If I am trying to 'fix something' and the patient arrests while I am fixing them, I have a moral imperative to do CPR, so that the patient does not die as a consequence of my actions."But if the patient understand they may die on the OR table and is OK with that risk, could they still be DNR? Or would the surgeon/proceduralist refuse on moral grounds? Or statistical grounds since this may affect their mortality rate with surgery? Do bath aides get to rescind a DNR if a patient dies during a bath? That sounds absurd but you have to extend the ethical argument to the simplest form:
While operating on/bathing/touching/talking to a patient, they cannot arrest without an attempt to resuscitate them, otherwise I am culpable in their death, regardless of their preferences of resuscitation.That ethical conundrum happens all the time in hospitals, but is rarely discussed in an academic or patient-centered fashion.
One of the more confusing or biased sentences was this one:
"How great it would be to send her off to rehab now, close the case and blast the DNR commies to hell." (emphasis mine)
Who are these "DNR commies" of which he speaks? Is it the family who advocated for the DNR in the first place? Or is it the dreaded Palliative Care Team with 'Dr. Greg Reaper', and Nurse Mel Anne Coley' who spent 90 minutes with the patient and family talking about what their goals are? If someone can point out the "DNR Commies", let me know who they are. You might be able to identify "DNR Commies" by their obvious use of symbols. Instead of a Hammer & Sickle they have a Defib Paddle and a ET tube.After the surgery she had complications, and the family put limits on the amount of aggressive care to pursue and she ultimately died. Dr. Haig recounts the phone call from the night nurse and then reflects on the actions and events that before her death.
"A waste of effort, of time, money and blood is how many in my medical community would have described our dealings with Carmela over those three weeks."The author is probably being a bit pessimistic about health care, as I think many in the medical community would actually say that he and the other doctors tried to do what they could given the goals set by the family (and presumably the patient). Aggressive but not too aggressive is an option, and shows good doctor-patient-family communication over goals. Compromise is not always a bad word.
The last paragraph left me flummoxed.
"But was it the DNR that killed her? Indirectly, maybe. I think it was realizing that her daughters planned to withhold care that made her give up."Followed by:
"An old teacher of mine explained it this way: "I will neither give a deadly drug nor will I make a suggestion to this effect.""Now he is mixing metaphors; Withholding, euthanasia, and physician-assisted suicide are all implied in this last paragraph, leaving the reader more confused. While I think this is an important topic, I am surprised it came out so ethically and emotionally confused. Maybe that was the point of the article, is that dealing with death in medicine is awkward and confusing for many.
Luckily for Pallimed Readers we have an upcoming interview with Dr. Pauline Chen, the author of FINAL EXAM: A Surgeon's Reflection on Mortality (now out in paperback). So look for that in the next few posts, and if you have read the book (or not) and have any questions for her, feel free to email me at ctsinclair @t g.m.a.i.l d0t c0m.
2)
Jane Brody, health columnist in the New York Times, made a personal appeal to encourage readers to look closer at the underlying issues of requests for hastened death in dying patients. She presents personal anecdotes and is fairly balanced on the issue, but leans more towards considering legalizing PAS. She does highlight Dr. Timothy Quill's 2004 NEJM article on helping his own father die (subscription req'd). For newer people to palliative care, Quills article is an important one to read if you have not yet already. As palliative care practitioners we are asked about hastened death by patients and families all the time, and given that it is only legal in Oregon (PAS only), we must understand how to respond compassionately to these requests, understand their root causes, and practice within the full scope of our legal guidelines.
Medicare Hospice Cut?Hospice Guy at Hospice Blog has a good review post about the "cut" in the expected hospice reimbursement for the Medicare Hospice Benefit in the President's proposed budget. His final take is don't get too riled up about it.
ECMO Prognosis
ECMO survival is hard to predict, but do note the high 30-day mortality rate of 37.5% in this study which looked at possible prognostic factors for survival on ECMO. The researchers did not find any, but they did get 80 patients. Unfortunately it took 16 years to get that many, so I don't expect to hear much about prognosis in ECMO for some time given the difficult accrual numbers.
Nude Hospice Calendar
Some hospice patients are so dedicated to raising money for their hospice in the UK that they are planning a "tastefully done" nude calendar. (via mental floss and Wigan Today) Wigan and Leigh Hospice seems to be a pretty progressive hospice seeing as how they also have a Hospice Real Ale made for them by a local brewer, and are the charity of choice for a local Starbucks. Good development department there!
"DNR Commie" Image Created by Christian Sinclair
8 comments:
'Flummoxed' seems an appropriate description to this all over the map piece which is a good demonstration of physician angst about death and dying (love that it was the DNR decision that killed her...'made her give up'...and not her multiple medical complications...death, again, is always a failure, someone or something's fault, something that could have been prevented if someone did something differently, and not something that happens to us all, and will occur no matter what amount of wise medical and surgical care is provided).
Rescinding DNR orders in the OR is reasonable: if a patient is well enough to go to the OR, and given the possibility of acutely reversible anesthesia/surgical mishaps, it is reasonable to 'hold' a DNR order for an operation. Cardiovascular mishaps in the OR, while not a good thing(!), do have a different natural history than other arrests. However it should be part of an informed consent process for the surgery and I think institutions should be flexible for those rare instances in which it is inappropriate. The whole code status thing suffers from absolutist thinking (from all directions) and a focus on making preemptive decisions about forbidding (or not) medical interventions without necessarily regard to different circumstances in which such interventions are more or less indicated/likely to be helpful.
E.g.:
intubating a patient who has suffered a cardiopulmonary arrest due to pna/copd exacerbation: very unlikely to benefit patient.
intubating a patient with pna/copd exacerbation semi-electively for ventilatory support - prognosis for recovery/restoration to health is pretty good (and often underestimated).
cardiac compressions and pressors in someone who has an in hospital cardiac arrest: highly unlikely to help.
cardiac compressions and pressors in someone who arrests or who bradys down or who has vascular collapse during an operation: more likely to help than the example above.
the issue here is that the interventions are less of an issue than the context of why those interventions would be considered otherwise'indicated.' a simple dnr/dni order cannot accomodate this in all cases and while a straight-forward and blanket dnr/dni order may often be appropriate it sometimes is not. I don't know how man patients have told me gosh i wouldn't want all that (cpr, intubation) if it wouldn't help me, but if it would restore me to health of course i'd want it. seems quite rational to me and while it's easy to figure out certain circumstances when these things won't help people (most in-hospital arrests; particulary with advanced medical illness; in the imminently dying) there are circumstances in which well maybe they might (in the OR, if you're choking on a peanut, etc.). simple dnr/i orders can't really accomodate this complexity....
Thanks for clarifying that point on the DNR in the OR. While the rest of my post left me little room to elaborate on that issue, it is an important one to ethically dissect, as you did in your comment.
Unfortunately the discussion I have often overheard amounts to 'not on my watch' which may be the same outcome (code in the OR) but seems inelegant and too blunt for such important decisions. It would be nice to see a detailed ethical analysis of all the factors that go into the decision of DNR revocation during procedures/operations. Anyone got to time to write a paper with us?
Drew,
Sometimes I wish I were one of your students or fellows, especially when you are on one of your "context" riffs. You have a way of cutting right to the stuff that is needed to make/recommend a clinical decision.
Tom
It must be wonderful to be so all powerful that one (as a physician) sees that death could have been prevented in an elderly patient with multiple medical problems.
I have come to recognize that a fall / hip fracture is probably a symptom of decline, rather than the cause of the final decline. I can think of several hospice patients who had hips pinned, went through some amount of rehab, then came back on service for several weeks before they died. I also recall several who came on service when surgery was not indicated.
My own experience with my 92 year old mother (E S Cardiac Disease) who had her foot broken by a revolving door at the hospital, followed by immobility, a blood clot, unsuccessful rehab, and 10 days as a hospice patient has underscored that there is a limit to what medicine can fix. You can resolve the clot, but you may not be able to resolve the underlying condition (E S Cardiac) that caused the clot.
We are not immortal. Some of us live longer; some of us live not so long. Our body is a wonderful machine, but it will, at some point, wear out and fail each of us. When that happens, my wish for my hospice patients as well as my family members is that their symptoms be managed and that they have time with friends and family.
Judy Goldthorp, RN, CHPN
Tom: ask my students/fellows first before you start envying them...but thanks.
Christian I never congratulated you on your 'DNR Commie' icon - it's rather perverse and I hope you find a future use for it.
Judy thank you for your comments and sharing your story. We are more than our plumbing and our fixable parts and realizing that can be really difficult (for doctors at least).
Drew, Thanks for noticing the DNR Commie flag. I hope that gave a few people a chance to chuckle. It was pretty fun making it. If anyone uses it in a talk let us know! I would like to hear what Scott Haig thinks about it.
Judy, Thanks for your comments. The hospice patient with a hip fracture always brings up some interesting dilemmas. (This patient is different then the one who gets a hip fracture and then goes to hospice services.) I have had some of my most interesting goals of care discussions with patient/family units in the hospice patient with hip fracture. That situation is a great example where palliative and curative can be one in the same and worlds apart all at the same time.
You spelled resuscitate wrong.
Fxed it! Thanks.
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