Thursday, April 30, 2009

Pall-Pourri: Radio, CPR in hospices

1)
WBUR (a Boston public radio station) has produced and broadcast a multipart documentary on end of life care in the US (Quality of Death: End of Life Care in America - Inside Out), with a major focus on palliative care, and balancing life-extension with quality of life and cost. It lays these issues bare, and even talks about research into providing palliative care specialist services early in the course of a disease. One of the segments actually involves a patient talking about how grateful he was for a palliative doc to talk with him frankly about dying instead of continuing the cheerleading. Wow. And it talks about how frank discussions are important for improving end of life care, as opposed to advance directive documents. Wow Wow.

(You can listen online; it's a little tough to find - go to the bottom of the page and click on 'listen' - it's small text towards the bottom.)

Thanks to Dr. Suzana Makowski for alerting me to this.

2)
BMJ has two editorials debating whether hospice facilities in the UK should be exempt or not from blanket NHS guidelines on cardiopulmonary resuscitation (yes exempt; no not exempt). Much of the discussion is about specific details of the NHS guidelines, and the structure of hospice care is different in the UK than in the US of course (ie many of these patients would not be considered 'hospice' patients per se in the US model), but it's interesting reading nonetheless. Both editorials are written by palliative care clinicians; this is a debate internal to the palliative care community. The Yes folks' major argument is with the national guidelines which create an opt-out system: resuscitation should be attempted unless patients opt-out. They argue that for hospices it should be an opt-in system. The not exempt folks basically argue this: hospice care is supposed to be state of the art medical care and by claiming exclusivity hospices are distancing themselves too much from mainstream medicine. Basically it's an argument that the movement has been claiming that it should be part of routine, mainstream healthcare and it's not a time to begin claiming exclusivity, particularly given now that palliative care settings are now seeing patients earlier on in their illnesses.

They also note that the guidelines say that if there is no realistic prospect of success then CPR shouldn't even be attempted. While we don't have national guidelines in the US, that is in fact a professional standard** here yet we all know that it is routinely ignored and very few people feel comfortable making a decision unilaterally at the time of an arrest if a patient has no prior do not resuscitate order. I can't imagine it's much different in the UK.

Anyway - I'm curious as to what those of you who work in hospice facility settings think of this, and what your facility standards are, and how much of a real-life issue this is (or not) - responding to requests for CPR in otherwise dying patients in hospice facilities.

**I'm ignoring New York state, the VA system, and local institutions and more talking about the broad professional-ethical consensus that physicians have the right to decline to provide medical care/interventions they judge as having no realistic therapeutic benefit for a patient whether it's an aortic valve replacement, chemotherapy, or CPR.

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