Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, May 06, 2008

Just (Don't) Do It

A previous post of mine discussing the fact that the "last year of life" is a retrospective designation was not, as some have misinterpreted, meant to be about futile care. This one is.

Futile care can be defined as medical intervention with no hope of prolonging life or easing suffering. Although there seems to be substantial agreement that determining the futility of a specific intervention for a specific patient can be difficult at times, many practitioners (or at least several bloggers) feel quite confident of their ability to do so. The Happy Hospitalist has said (in my comments) that he is 100% certain he can predict on admission who will not leave the hospital alive. If so, then why does he proceed to hook these patients up to nine IV pumps? Panda relates similar stories of demented grannies (his term) sent over from nursing homes to be tortured to death scheduled for surgeries and other endless treatments that are clearly futile.

So why do it?

Why do you go ahead and admit someone to the ICU if you know they won't live? [Note: I'm not talking about borderline cases; I mean those patients you really do *know* won't make it. You claim to know who they are, and I believe you.] Why do you consult the surgeon when nothing he does will make a difference? Why don't you stop? Why don't you say NO?

I know what you're going to say: "We don't know the patient. The families are strangers to us. We don't have the right to say no; to initiate these kinds of discussions. That's your job; the Family Doc. It's your long-term relationship with the patients and families that makes you the person to have those difficult talks, helping the families come to grips with the idea that medicine can't do anything more. It's not my place."

Bullshit.

You're the treating physician. You seem to have no difficulty forming relationships quickly enough to tell someone they need emergency surgery, and heaven knows you have far more experience than I conveying tragic news in the case of horrific trauma. You're the one standing there in the room with the patient, certain that nothing you do matters [a determination I'm agreeing with, mind you.] Whether or not there's a formal DNR order in front of you, all 50 states have legal protections for physicians who refuse to provide futile care. Yet you go ahead and intubate; start the pressors; call the ICU. Somehow you manage to grow a backbone and refuse inappropriate narcotics to blatant drug seekers. This is no different, no matter how you protest.

If managing the problem if futile care is important (and given the demographics of aging Baby Boomers, I would say it is rapidly becoming critical) then we all have to step up to the plate and do something about it, by not doing what shouldn't be done in the first place. I have two concrete suggestions (to be discussed in future posts) but first and foremost, you -- the ER docs and the hospitalists -- must stop passing the buck back to us, the primary care docs, to help patients and families make end-of-life decisions.

Don't tube that demented old granny. Explain to the family why it's not appropriate to put dad in the ICU. For heaven's sake, stop thinking "Hospice" is a synonym for "we give up"! When faced with a terminal patient (and yes, we all know dementia is terminal; why can't we face that?) just don't do it.

It is your job.

26 Comments:

At Tue May 06, 07:12:00 AM, Blogger CrankyProf said...

"Hospice" is a term for "we give up!" Or more properly, "we can't do anything more to fix this -- it's in God's hands."

No shame in that.

Part of the problem is that it has become declasse to die. Even the very language of death has become taboo -- no one "dies," they "pass on" or (barf) "pass in to eternity." It's not a "coffin" or "casket," it's a "remains receptacle." No funerals, please -- we have "memorials" or "remembrance ceremonies."

Everyone has bought in to the idea that they can live forever, given the right drugs.

It's OK to just flat-out acknowledge that someone is going to die. Sooner, rather than later. Unpopular, and probably hella uncomfortable to just say...but people die.

 
At Tue May 06, 08:17:00 AM, Blogger WardBunny said...

I can't understand this urge to torture some ICU patients. I've even heard consultants say that the patient wasn't an appropriate admission.
Why? It's not like you'd treat a pet that way.

 
At Tue May 06, 09:27:00 AM, Blogger mark's tails said...

Hammer. Nail. Head.
Nice post Dino.

 
At Tue May 06, 10:22:00 AM, Anonymous ndenunz said...

It is the path of least resistance.

 
At Tue May 06, 01:12:00 PM, Blogger Buckeye Surgeon said...

Good post. Once the ball starts rolling down the hill, it's hard to make it stop. Whoever initially gets the ball rolling needs to be held accountable to some extent. The 98 year old who rolls in to the ER septic from peritonitis automatically gets into the ICU with ID, GI, surgical, and Pulmonary consults on board. But the ER/hospitalist doc is the one at bedside at that moment. It can all stop right there if handled in a professional, empathetic manner.

 
At Tue May 06, 01:23:00 PM, Anonymous 2nd year vet student said...

wardbunny:

Some people DO treat their pets that way. The types of things people do to their animals at the end of their lives is one of the many reasons I'm not going into small animal medicine.

 
At Tue May 06, 01:27:00 PM, Anonymous Anonymous said...

It is always ironic, in that perspective is contingent on what side of the fence you are on. I am a practicing hospitalist, and not a week goes by that I admit a patient on the precipice, and not once has their PCP discussed EOL issues or ADs. Take home: everyone is at fault, and it is all our responsibilities. Both sides could be doing things a lot better. The promise of paymetn integration, and improved IT and interconnected EMRs might step up the game.

 
At Tue May 06, 01:46:00 PM, Blogger Midwife with a Knife said...

I have to agree with anon1:27. It's everybody's responsibility. Just like when babies are born at a previable age or with a collection of birth defects that aren't compatible with life. It's our responsibility as MFMs to explain to the patient why providing certain care to the newborn won't be appropriate, and what will be appropriate. It's also the neonatalogists' responsibility to not put babies with lethal pulmonary hypoplasia on the ventilator (for example), but in the end, ensuring that the patients (mother and fetus) both have appropriate care and end of life discussions is everybody's responsibility.

The issues with 98 year old demented grannies with peg tubes being tubed and vented is a problem that belongs to the system, both to the primary care docs and do the hospitalists that take care of these patients once they're in the hospital. Instead of blaming each other, you guys should work together with these patients.

 
At Tue May 06, 02:39:00 PM, Blogger Nurse K said...

Come on now---a lot of patients with head bleeds 'n stuff come in needing immediate intubation or have already been tubed by the medics. It's impossible to be psychic and know what the underlying cause of the decreased LOC is without a CT and no ER doctor is going to send a patient to CT without having their airway secured.

Once the patient is tubed and if the tube is keeping the patient from dying, you can't just extubate on your own without family consent. Maybe you can legally, but no one is going to do that. Alas, admit to ICU and let them work it out. Sometimes the decision to extubate involves brothers, sisters, daughters, sons, wives, etc.

 
At Tue May 06, 02:42:00 PM, Blogger Nurse K said...

I should add that if the patient is not DNR/DNI (with documentation), they are assumed to be full code until proven otherwise in the ER. Sometimes a health care directive is scanned into the chart, sometimes they come with NH documentation, but many people have no such things accessible to ER staff.

 
At Tue May 06, 02:48:00 PM, Blogger Thaddeus Mason Pope said...

Strong words, well stated.

But perhaps too strong. The law may not necessarily support stopping. And is inability to leave the hospital alive the right measure of for whom aggressive measures are inappropriate.

(I expanded on this am little at http://medicalfutility.blogspot.com/2008/05/stop-it-right-now.html

I look forward to more posts on the topic.

 
At Tue May 06, 03:38:00 PM, Blogger The Happy Hospitalist said...

Yo. I have these discussions every single day when I'm at the hospital. I have many success stories. Families who understand that granny is dying. Who understand that it's time to go. It happens every single day. Withdrawal of care. Sometimes we have 5 or 6 people in the paper's obits that week. That's end of life discussions.

However, there is a very large subset of population that doesn't get it. That despite all the recommendations for hospice or DNR, they refuse to accept that the end is near. You are asking me not to perform CPR in a patient that requests full code status. You are requesting me not to intubate critically ill grandma who's POA says do everything. Until I am given full immunity from legal prosection for negligence or failure to diagnose or failure to rescue, then end of life full code rescue will continue.

If I suggested that I don't have end of life discussions, I misspoke. I have them every day. In fact, two patients of mine last week, one with metstatic breast cancer with bone mets and one with cirrhosis, persistent GI bleeding and an unrepairable TIPS both were recommended hospice. Both said no. Both are full codes. So Dinosaur, tell me what to do when they crash. Do I stand there and do nothing, against their wishes?

 
At Tue May 06, 03:56:00 PM, Blogger Pem said...

Two perspectives. I grew up in the north and now teach in the southeast and the culture is very different. Students here seem to always go home when a grandparent is maybe dying. So I imagine there are a lot of families who want the person kept alive until the family can gather. It is kind of like the wish to time a birth for convenience. Are doctors discussing families wanting to time a death?

My husband was recently diagnosed with Lewy Body Dementia, at age 62. My grandmother died of Altzheimers after many years of decline including a good three years bedridden, not knowing anyone, at home with nurses (and I think even then it took help). My impression is that the problem with dementia is that it is not terminal enough--you have to hope the person dies of something else first.

 
At Tue May 06, 07:54:00 PM, Anonymous Anonymous said...

I suspect that a lot of what drives the insistence of some families on futile care (besides a s*&tload of guilt, reasonable or not) is the fact that THEY DON'T HAVE TO PAY FOR IT. A lot of this would stop on a dime if these people were responsible for even a fraction of the cost of this "care." Excuse me now, I have to go arrange to have "DNR" and "no PEG" tattooed in the appropriate places. And Lord save me from some nutjob do-gooder who thinks everybody needs to die with at least 1 tube.

 
At Wed May 07, 12:06:00 AM, Anonymous Anonymous said...

I had an elderly nursing home patient, about to be admitted for unstable angina. She didn't want to stay in the hospital. When the admitting doc asked what we should do in the event that her heart stopped, she paused and replied, "um, bury me." She got discharged instead.

 
At Wed May 07, 12:09:00 AM, Blogger janemariemd said...

I think that part of the problem is that people are given a choice for something they ought not to get; ie, the happy hospitalist's patients above should not be "full codes" in my view, but on the other hand there is a difference between being on hospice and being a "no code". I try to start with the latter, which is pretty narrowly defined as no resuscitation with CPR/cardioversion/intubation, and then go from there. Of course, it's not so hard for me with my patients, whom I mostly know well. When you never knew the patient before you admitted them, it can be a very uncomfortable discussion, and sometimes it seems like the patient and family never really thought about death or resuscitation, despite the fact the patient is in a very bad way, right then and there.

I think the last anonymous poster is right--and focussing on specific problems and treatments allows patients and families (and the medical team) to avoid the vastly more uncomfortable issue of the patient's mortality.

 
At Wed May 07, 09:13:00 AM, Blogger mark's tails said...

The Happy Hospitalist wrote, "Do I stand there and do nothing, against their wishes?"

HH I'm not picking on you, as much as it is frustrating it also becomes a moral dilemma.

There is an interesting post by
Bob Wachter
in which he did do just that, nothing.

 
At Wed May 07, 09:19:00 AM, Blogger The Happy Hospitalist said...

Mark, I remember reading that and applauded loudly. Unfortunately, it only takes one irrational family to find a lawyer to drag you through the mud for failing to rescue their granny.

Intellectually, I know doing nothing is the appropriate answer. Legally, I have nothing to stand on.

 
At Wed May 07, 10:14:00 AM, Blogger Teresa said...

Intellectually, I know doing nothing is the appropriate answer. Legally, I have nothing to stand on. --HH

Therein lies the problem. There are so very few lawsuits against doctors for saving patients that should have been allowed to die.

In our culture, people are less horrified (and sometimes impressed) when people are kept alive against the odds than when they are allowed to mercifully die. I think a part of the problem is that people don't want to slip over into physician-assisted suicide. I am not a proponent of physician-assisted suicide, but there comes a time when intervention to preserve life is torture.

If only we could get people educated on what EOL conditions often involve when extending life beyond what God has clearly ordained.....

 
At Wed May 07, 06:57:00 PM, Blogger WhiteCoat said...

Teresa -
Suppose that a physician let someone in a family die against the family's wishes - no matter how extreme.
There is certainly the possibility of a lawsuit.
In the emergency department, there is the threat of an EMTALA violation.
The family will go and tell everyone that "Dr. Kevorkian" let poor momma die. All momma wanted was to be able to watch junior graduate from college before she died.
Newspapers may pick up on the story about how Dr. K is the heartless SOB who let some poor patient die rather than trying to save her.
Once that happens, the hospital has to take action against Dr. K or risk looking heartless, too.
Then Dr. K has trouble getting on staff somewhere else.
The past of least resistance is to do what is ethically suspect.
Unfortunate how our society works, isn't it?

 
At Wed May 07, 09:02:00 PM, Blogger Lisa said...

I spent 8 years working in ICU. I left because I burned out on putting people through hell before they died. Ironically, I now run a skilled nursing facility. I love the relationships that I have with our elders, and don't miss ICU one little bit. I'm blessed to work with a group of attendings who aren't transfer happy.

 
At Wed May 07, 10:07:00 PM, Blogger Teresa said...

Dr. WhiteCoat, I agree with you. A doctor's decision to intervene with life-extending treatment in a patient who clearly needs to be allowed to die in peace is self-defensive medicine. And I don't blame doctors one bit, for the reasons you articulated.

That's why I say that our culture needs to change. It needs to become more acceptable to die in hospice-like conditions. Most laymen do not have enough exposure to the realities of tubes and torture to understand why it is so important to let their loved ones die in peace. If this were a COMMON value, then ED/ICU physicians could more easily inform the family that "it's time" and get the patient to a place of comfort for whatever time they have left.

As long as our society as a whole values life under any conditions above all other desirable outcomes, we will continue to have this problem.

Hey, Dateline or 20/20, if you're out there reading this, you really need to do a lot of stories on this topic. The media has repeatedly changed cultural values. This would be a GREAT one for the media to pursue. Once people are sufficiently exposed to and horrified by EOL conditions, they'll start to understand the rationale for comfort care only decisions.

 
At Thu May 08, 08:46:00 PM, Anonymous Anonymous said...

Dino as former PCP, hospitalist, and now a subspecialist let me ask you. When is the last time you managed a patient like this in the hospital? It is easy to pomtificate from some outpatient clinic about what should or should not be done. In all my years of medicine I have NEVER seen a doc outright refuse aggressive care when the patient or family were absolutely adamant about it. Is it right? no. It is very simply the type of unrealistic society we live in. Before calling me a wuss you should know I have been referred to my own state medical board for "aggressively" discussing supportive care in a futile situation. Have you? Also, as a hospitalist doc I would see patients EVERY DAY with endstage chronic diseases whose PCP's had NEVER discussed end of life issues. Now why is that dino? In my hospitalist days I could count the number of outpatient PCP's on one hand who came to the hospital to help these patients and there families make these tough decisions. Now why is that dino? Don't talk to me about cop outs. Dino, I've done your job (and I am not saying it is easy). I've done HH's job, I have an idea. If you are so idealistic about this issue, why don't you step up to the plate and admit your own patients instead of pontificating about how they should be managed. Most hospitalist's I know are so overworked they would happily give back patients to the PCP's. Think about it.
PS Buckeye: Refusing to do surgery is one thing (and you know it). Refusing to aggressively treat a patient is a completely different issue. Sometimes, no matter how professional and empathetic you are the patient/family will want aggressive care. period.

 
At Thu May 08, 10:26:00 PM, Blogger Manda said...

From a patient/family perspective I think the issue is fraught with emotion. Wives, children, brothers and sisters have not made peace with the patient and cling (while causing further pain) to the patient. My Dad died 5 years May 3rd, most of us had all made our peace and my Mom watched him die from his final heart attack under a DNR order. My siblings that had not made peace with Dad, kept wondering why more wasn't done. Well maybe because the MRSA, congestive heart and diabetes had already caused enough damage. Maybe it should be handled from an emotional perspective - "he/she will be in more prolonged pain" etc.

 
At Fri May 09, 06:13:00 AM, Blogger #1 Dinosaur said...

Anon 8:46 (and by the way, your case is weakened somewhat by posting anonymously): Just because people insist on "aggressive" (ie, inappropriate) care doesn't make them right. If someone insisted that a post-op patient didn't need pain meds, would you withdraw them? Professionalism and empathy are irrelevant, in the sense that they don't change the central fact that futile care is inappropriate.

I agree with other posters that the central problem is families (sometimes patients) who feel they have the right to demand this kind of care. All I'm asking is for the hospitalists to work with me in changing those expectations.

 
At Sat May 10, 09:48:00 PM, Anonymous Anonymous said...

Dino:
Did you actually read my post. Did you address anything I said? (no)What the hell does inappropriately withdarwin pain meds have to do with this situation (nothing). Look, I happen to be really good at "the talk". Lord knows I have done it enough. The vast majority of the time I can convince patients and/or families to look at supportive care. But not all. No matter what you say to me I know you have not convinced every one of your outpatients to be a DNR when needed. What do you do, ban them from the ER when there end-stage disease is exacerbated? No, you refer (dump) them on the ER and make it someone elses problem and we both know it. It is easy to pontificate from the chair of your outpatient office and proclaim what should and should not be done in the hosptial. It is a little different to step up to the plate and act on your beliefs. I will say it again, quit whining and start admitting your own patients. Then it will be YOUR call. About me being an "anonymous" when you post:

"As it happens, Dr. Klinghoffer was in charge of coordinating third year clinical rotations when I was in medical school; a distinction that poses little risk to my anonymity, as it applies to multiple thousands of students"

I will take it with a grain of salt.

Lastly, given that I have seen you bash the: ER, radiology, hospitalists, pharmacy, and god knows who else, I frankly see I very unhappy person who really needs to take a hard look at a new career.

 

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