We often write about good saves. Now I’m going to write about a bad one. When a 96 year old, demented, bed-ridden man has a cardiac arrest in the nursing home, nature should be allowed to take this tortured soul from this earth. I don’t care if for some reason the patient has no DNR. I understand the nursing home has to call the code – but when I say call, I mean that with a grain of salt.
It means you do a slow code. It means you press lightly on the chest. It means you put weak effort into the bagging. It means you go easy on the ACLS meds.
So wouldn’t you know it – my medics pushed a little bit too hard, gave too good of respirations,and went too heavy on the epinephrine. They went and brought the patient back.
Bastards. Save that for the patients that have the potential to go on living.
23
Dec
Zolotta, I think you must have had an awfully unsatisfying life recently to enjoy riding your high horse as much as you do.
“When there are situations where the family decision is unreasonable, I call for an ethics review– before the patient codes! This takes only hours or less. A panel of usually three physicians assesses the situation, and determines whether resuscitation would be needlessly painful or cruel. And then, being honest folk, we explain this to the family.”
Besides the fact that ERP is not saying that DNR notes aren’t honored, you might have missed the fact that, in the entry’s sample story, there was no DNR note, and possibly no relatives to care for it. Ethics review and discussion with relatives are only possible – as you stated – before the worst case occurs. No one here wants the details of the above case, because it’s anonymised, short on details for privacy reasons and good this way.
You certainly have some valid points as well – as does ERP, this doesn’t need to be contradictive – but honestly, if you’re doing a full code on an old, multimorbid(sp?) vegetable who had zero life quality to start with *before* the code-able event happened (where there is nothing to improve, which every onlooking doctor would confirm – we’re not talking about some person with lots of hopes and chances for a good outcome), and who has no relatives, you are not acting as a responsible doctor. Of course , and here we agree, I think, it is bullshit when medical professionals “play god” out of sheer egomaniac joy, but to pull on an extra high morals’n'ethics facade just to avoid making a right decision that is not 100% forensically safe, is just as false.
Medical professionals vow to help people. Prolonging suffering in doubtless cases is NOT helpful.
If there’s no family, then someone else (the physician) needs to make the decision and have the patient legally declared DNR before they arrest. Making the call on the spur of the moment, the first time you lay eyes on the patient in the ER, is just irresponsible and wrong. When you don’t know the whole story is when mistakes are made.
As a lay person who volunteers in an ER and with advanced dementia hospice patients I’m leaning toward supporting Zolotta’s position here, much as I sympathize with ERP’s. Yes, it seems everyone agrees, the patient “should” be allowed to die DNR. The problem is that the life-death decision is not within the moral scope of practice of the physician. Only the patient and the family members, if the patient is incompetent, can make the call. In the absence of a directive, code protocols need to be followed. If doctors on their own authority can pull the plug (slowly or quickly), we’re on a slippery slope of violating basic human rights. Yes, the patient and family have abdicated their responsibility, but it doesn’t follow that the physician inherits the power of life and death. Saving a life cannot come to mean saving only the lives I think are worth saving.
Prolonging and increasing the patient’s suffering and increasing the cost of pointless care are terrible outcomes, but sometimes we have to accept terrible outcomes in order to preserve the rule of law and the inalienable rights of human beings.
There’s no getting around the fact that a “slow code” is tantamount to saying, “It’s time for this patient to die now.” It IS time, but that’s not up to the care provider to decide.
Okay, turning this around since I’m not religious but have read enough christian statements along the lines of “it was HIS (God’s) will that he was taken from us”…
If you’re so adamant on not playing god by “taking one’s life”, how can you be so confident in trying to keep a poor soul from ascending (well, or descending, whichever) to heaven when apparently his time has come? That sounds somewhat hypocritical to me and my atheist ears.
(…)”but sometimes we have to accept terrible outcomes in order to preserve the rule of law and the inalienable rights of human beings. “(…)
This is the one point where I strongly disagree. Any human has the right of dignity, or not?
Laws have flaws, and while the law is applicable and correct most of the time (and necessary to aid our society as it is), there are exceptions when it doesn’t “fit”, or rather, where no rules for the individual case exist.
I think people forget that the oath that each doctor secretly vows to abide to (not the literal hippocratic oath) does not mean that a doctor has the duty to prolong suffering, only because anything else would be against the law. A qualified, humble physician has to be able to make decisions that borderline between what the law says and what it doesn’t say. No one says that they can decide on a whim that “all old people may die” or anything like that. In the rare occasions that a strict following of the law would not permit someone to die, only because no one signed his paperwork, it would be straightforward unmoralic to force life into a near-dead body.
Or maybe it would make everyone happier if we settled on the following: 1.) fully code vegetable person with no life quality into an ICU-able state 2.) hold council of ethics and decide DNR is appropriate 3.) wait for another couple of weeks until the next code comes up and now let pt. go with forensic safety of DNR. What do you lose? Thousands of tax dollars, weeks of a blocked ventilator bed in an ICU, human dignity of the finally released pt. But yay, we followed the law and wash our medical hands clean of any responsibility.
Surely this is a complicated topic with more than one right answer, but still my personal opinion stands. It’s good that we have ERP and Zolotta, because to each their own. As it happens, mine isn’t the latter.
Arzt4: your step one glosses over the main error. If I know that the patient has lost all consciousness and quality of life, it is part of my job to have already addressed the issue of code status. When I’ve done my job properly, we never resuscitate someone for whom we know it would be futile or cruel.
If I haven’t had this opportunity because I never met the patient before, that also means I don’t know them well enough to know what their code status “should” be. Not even the best doctor can look at a new patient in cardiac arrest and know whether they have quality of life. That kind of examination takes a certain amount of time and care. It must never be a snap judgement.
I am sure no one here voted for snap judgements. When you’re called to a nursing home, you can get the history from the nursing staff and the papers. Being bed-ridden, tube-fed, 100% immobile and highly demented would be documented in the chart and available for you to review quickly (again, we’re not talking about some vital oldish guy keeling over in the street with no known history at all). Without available information, you got a point.
Doctors actually have to do what is best for the patient, and when someone can not articulate themselves, they need to assume what the patient’s wish would be. Naturally, the “normal” expected wish would be to survive, you’re right with that and I don’t debate that.
Doctors are not lawyers, and they must find an indication for any procedure they do. They do however get into situations where no indication for a full code is given, i.e. when the natural process of dying has set in (the borders from ill to dying are very fluent as you must know and thus there can’t be any fixed rule for when to reanimate and when not – each individual case is different). *You* are the doctor, and *you* are – by means of your qualification and education – qualified to estimate whether or not a reanimation is indicated. If it is not indicated, you have no obligation to do it just because the relatives or anyone wants it. It is not the relatives decision, it is yours, but of course you should decide responsibly based on not only written law but also on for example your experience with intensive care patients, nursing home patients and emergency patients etc.. When it is indicated, of course you have to do it (well, as it would be neglect to not do what’s indicated).
I should say that I’m probably in another position as Germany probably has differently laid out law texts for this than the States do.
The whole discussion is positive, however, as it shows that people do care, and think about it from different points of view. If we had no moral or ethics, no one would care, and no one would mind. The discussion, as diversified as it is, shows how well our societies work. We are very privileged – in other times and other places discussions like that would not have been possible. So thank you for the exchange, even though we won’t come to a total agreement. I’ll leave it at that. :-)
[Just clarifying that particular bit, because I think I wrote that pretty confusing after my day at work, haha... remember, this is according to German law and might be differently settled elsewhere. Also, here the emergency doctors go from a special delocalization to the scene and just drop the patients off at the ER for the hospital docs, we have no paramedics as you have, "just" ambulance crews who're called paramedics too, but have very limited scopes of action, i.e. no intubation etc., as for these the emergency physician will be called to the scene.]
If you do not see the indication to reanimate, and document it on the chart that way, then it is _not_ against the law to refuse doing a full code.
Much simplified(!) sample from real life: 100% disabled and out of it vegetable patient in nursing home, found on scene in agonal respirations. Document in chart: pt. found in agonal respirations, in natural process of dying. No reanimation commenced.
I’m just now coming across this discussion (and this great blog); I’m really interested to know what the law actually says about what has been called “medical DNRs” here (DNRs against the family’s wishes).
I work as a nurse in the States and have seen a few instances of doctors making a patient a DNR despite the family’s wishes; although most of my experience is in pediatrics, so maybe that changes things? I have, however, never seen it done in the heat of the moment (i.e. in the ED when the patient shows up already coding).
I’d be really interested to know what the law says about this. We all know that doctors have the right to refuse all kinds of treatments against families’ and even patients’ demands, but does that right extend to codes?