I am a doctor working both in the UK and in Baltimore. Recently I took care of a patient at a hospital in the US who was bleeding to death. Advanced cancer was consuming his body. Doctors at another hospital said there was nothing more they could do, but his family desperately wanted him to live so they brought him to our hospital.
The fistulas in his abdomen were so large, his bowels were open to the air. Blood frequently gushed out of his wounds, necessitating blood transfusions and other desperate measures. The only way to stop the bleeding was to push hard on these wounds, which inflicted excruciating pain. Despite these aggressive treatments, there was no hope of long-term survival.
His family was not ready to let him go and so they told us to take any measures possible to keep him alive. In order to do this, I would have to crack his ribs during chest compressions and electrocute him in an attempt to restart his heart. Regardless of whether we could keep the heart beating, the rest of his body would still be irreparably consumed by cancer.
Continue reading “Hippocratic Hypocrisy: When It Comes to CPR, Is Less Care Actually Better Care?”
Filed Under: Uncategorized
Tagged: CPR, DNR, Elizabeth Dzeng, End of life decisions, Janet Tracey, Liverpool Care Pathway, NHS Dying Matters, UK General Medical Council
Mar 21, 2013
Here is a little appreciated fact: Patients cannot order medical care; they can only accept or refuse it.
Only a doctor can order medical treatment. In an extreme medical situation, the doctor can offer CPR, but it is the patient’s job to accept or reject.
Any patient can refuse CPR. This refusal is known as Do Not Resuscitate or DNR, and for obvious reasons needs to be made ahead of time. The question is, when is making the decision to be DNR appropriate?
A further definition is needed. DNR (and its colleague, Do Not Intubate, DNI) is not the same as DNT, or Do Not Treat. A patient, at their discretion, may receive maximal medical care, including drugs, dialysis and surgery, and still be DNR. The DNR order in that situation is simply a line that the patient will not allow the doctors to cross. “Do everything you can to help me, but if it fails I do not want to end my life on a machine or with some gorilla pounding on my chest.”
On the other hand, a DNR can be a part of a hospice or palliative care program, so that all care is focused on comfort and not treatment. It is even possible, in very unusual circumstances, to receive hospice care without being DNR. A DNR order is like any medical decision, it can be changed if appropriate. DNR is not the same as “pulling the plug.”
How aggressive to be in receiving medical care is a personal decision. In order to make certain that our individual desires are followed it is critical that, as much as possible, these decisions be made ahead of time. This avoids panic, confusion, and guilt. In that spirit, let us review a few cases.
Ben is a 54-year-old gentleman with lung cancer, which has spread to bones and liver and is growing despite the third chemotherapy. His doctors inform him that a fourth chemotherapy has a 5% chance of helping him and a 20% chance of killing him. He wants to try the chemo. His physician says, “OK Ben, we will order the chemo but if things fall apart and your body starts to fail and we cannot fix it, do you want to be put on a machine?” Do you think Ben should make himself DNR?
Ben made himself DNR. He survived the chemo, but the cancer progressed and he died one month later.
Continue reading “To DNR or Not to DNR”
Filed Under: Uncategorized
Tagged: Cancer, Chemotherapy, CPR, DNR, End of life decisions, James Salwitz, Oncology
Dec 14, 2012
Recently a patient with advanced lung cancer was admitted to a local hospital. Pain in his abdomen was diagnosed as a gallbladder infection.
Because he had metastatic cancer, in addition to the new problem, the patient and family decided that if things deteriorated he should not be given CPR or put on a respirator. A Do Not Resuscitate (DNR) order was entered in his chart. Treatment for the gallbladder was continued, but it was decided that there was a line that the doctors would not cross.
This made sense to me.
Try conventional therapy, but if he was too weak to recover, then do not continue treatment which could cause more suffering than benefit. Give him the opportunity to survive the gallbladder problem, but respect the terminal nature of the greater disease. We were all gratified when his pain and fever went away, and he recovered from the emergency.
When we were discharging him from the hospital, a surprising thing occurred.
The patient and family requested that since he had survived the infection, that the DNR be reversed. They decided that when a sudden new major medical complication occurred, that CPR be performed and he would be placed on a respirator. The clear protective line vanished.
In difficult lengthy discussions with the patient and family, it became clear that they were riding tides of emotion. When things looked better, they focused on life and “cure.” When things grew worse, they were ready to withdraw. They became defensive and angry at the suggestion that this decision might cause suffering. We were not able to redefine limits to his care.
Continue reading “Crossing the Line”
Filed Under: THCB
Tagged: CPR, DNR, James Salwitz, Lung cancer, Oncology, Palliative Care, The Insider's Guide To Health Care
Apr 24, 2012
I’ve played over a thousand ice hockey games in my life, but I had no idea that last month’s adult men’s league game in Cleveland would be the most memorable. I grew up in Canada, three blocks from Wayne Gretzky, the greatest hockey player ever, but I wouldn’t be surprised if my recent game was more important than any game that my former neighbor played. This game was literally a matter of life or death.
I almost didn’t show up to the game. I had just landed in Cleveland from New York City after attending a close friend’s wedding. I’d landed at 8:15pm, jumped in my car and dialed into a conference call for my organization uFLOW, arriving and finishing my call barely in time for the 9:30pm puck drop. I didn’t plan my schedule around the game; the timing just happened to work out.
It was close to the end of the 2nd period when I heard our captain, Brandon Dynes, yell something and race off the ice. I soon realized he skated off to call 911. I looked down at the end of the bench and saw that our teammate Harley was unresponsive. Harley is 69 years old (though could pass for 50) and as the eldest player in our men’s league has been an inspiration to many of us. I quickly went over to assess him and found he had no pulse, was not breathing, and not responding to verbal or physical stimuli. I was fortunate that the opposing team had a physician playing as well, Dr. John Wood, an orthopedic surgeon. John quickly came over and could not find a pulse either. Knowing end organ damage such a anoxic brain injury can occur quickly, I grabbed Harley and layed him on the bench and started compressions, pressing his chest extra hard knowing I was going through a layer of hockey pads. I later quickly ripped off his pads off to assure better compressions. Continue reading “Hockey Teams and AED’s Save Lives”
Filed Under: Uncategorized
Tagged: AED, CPR, Defibrillators, Hockey, Vipan Nikore
May 6, 2011