Friday, March 04, 2005

Great Response 2

Jan also put her two cents in. Two very valuable cents.

As a seasoned former ICU nurse, may I recommend asking your next patient who wants "everything done" for him exactly what he/she thinks that entails. When they look at you blankly, then explain that if they were to stop breathing or if their heart were to stop that CPR would be done. Then explain about the ETT and inability to speak, the fact that their arms will be tied down post arrest to prevent them from pulling out the ETT and/or any lines, that they will likely have fractured ribs - if the CPR was done well enough - and that they have a small chance of leaving the hospital alive, much less in a functional capacity.

When I worked in the MICU we admitted a patient from the ER with a severe COPD exacerbation - this was just after the DPAHC law took effect. While in the ER, the intern had apparently asked the patient if he wanted "everything" done to keep him alive. The patient reportedly said yes. As I was admitting him to the MICU and assessing him I asked the patient directly if he wanted to be placed on a ventilator if his breathing got bad. He (in the presence of his wife) definitively said no - he remembered how horrible it was to have been intubated in the past. So the patient was made DNR and died during his admission to the unit.

Many patients do not understand what we mean by "do everything". If it is phrased differently, then you may get diffferent responses. One of our end of life/hospice attendings gave a great lecture on discussing treatment preferences. He usually starts his discussions w/ pts by stating that some people prefer to live life as long as possible even if they suffer, whereas other people would rather focus on quality of life and freedom of pain even if it meant a shorter life. He suggested finding out what the patient valued - such as the ability to garden, or spend time at the race track or whatever - then pose the question about aggressiveness of care in relation to their values. If the patient was too sick to participate in whatever it was that was important to them, then he would suggest that not prolonging life, but focusing on comfort was a more realistic goal.

He really was good at what he did, and he encouraged me to practice this skill (of discussing end of life matters), but I changed focus and am no longer hospital based, so have not really honed my skills.

Photo can be found here