21 April 2010

The Arrogance of Hope

No CPR
A vignette:

We all stand around the empty gurney in the resuscitation room, expectantly. The tech uncoils the lead wires for the monitor and a nurse prepares her gear for starting an IV. After a minute or two of waiting, it's suddenly showtime. The paramedics arrive in a flurry, a bustling crowd of big, strong men in matching blue t-shirts flanking a gurney with a thin, pale figure on it. One pushes the cart, one trails the head, holding an endotracheal tube in place and ventilating the patient. One performs chest compressions, and another carries the monitor. The lead medic precedes them all, clutching a sheaf of EKG rhythm strips and a metallic clipboard. He breathlessly begins his report:

"63 year-old male, found down and unresponsive. Unknown down time. Initial rhythm was bradycardic at a rate of 25, agonal-looking wide complexes. Intubated and got a pulse back with epi, but lost it again in route." As he speaks, we all swing into action. The patient is slid onto our gurney and CPR is restarted. Another line is started. Blood is drawn and monitor leads are attached. I listen as I begin a primary assessment. I note the lack of hair on the patient's scalp and the marked wasting of the cheekbones, the cachexia of severe illness. I note the waxen color of the skin, pale even for someone in cardiac arrest. I shoot a quick look at the medic: "Do we know any past history?"

He replies, "Yeah." A pause. "Metastatic pancreatic cancer. Been through three rounds of chemo. Family says he's terminal." The entire room comes to a momentary standstill and all eyes turn to the medic. "He's full code," the medic says clearly but with a tone of resignation. Somebody mutters "Son of a bitch!" and CPR resumes.

We run the code for another ten minutes in more or less silence. A pulse is regained and IV drips begun to maintain the vital signs. The entire team is dispirited, but professional, and all the necessary tasks are performed. Finally, the registrar comes in and says "His family is out front, and .... here's his DNR paperwork." Turns out the family members who called 911 were not the ones who knew about his advanced directive. Every member of the team is frustrated and upset. We bring in the family, and allow them to be with their loved one as he passes away.

Later, when the ER is quiet, a two-AM bitch session ensues. One of the reasons we love Emergency Medicine is the opportunity to be there when it counts and to save lives. Codes, even when the outcome is bad, are very much our raison d'etre. We savor them for the adrenaline and for the occasional miraculous result. But there's nothing we hate more than the futile code. They used to call them "slow codes," indicating that the team just went through the motions. And worse than the futile code is the code that should never have happened. That poor man just wanted to die in peace and in the comfort of his home. And because of a mistake (nobody's fault) we brutalized him needlessly in his final hour. "It's a fucking shame, it what it is," one of the nurses bitterly comments.

Interestingly, the consensus among the ER staff is that when it's our time, we want to be let go in peace. There are mordant jokes about having the "No CPR" logo tattooed on our chests once we reach a certain age or diagnosis. That way the ER crew will know not to code us inappropriately. It's always surprised me how consistent ER caregivers are in their desire to be allowed to die a natural death, if death is indeed inevitable and appropriate.

Which is why I found this piece written by an ER doctor interesting, and a little upsetting. It was brought to my attention by Dr Sinclair, who blogs about end-of-life issues at Pallimed. The piece, written by a Dr Boris Veysman, initially published in the journal Health Affairs, was republished in the Washington Post and also appeared on NPR. It's centered around a vignette similar to mine (plus a prolonged self-congratulation over his own cleverness in accomplishing a resuscitation). However, the ER physician takes a very different approach after the DNR order is produced. Key grafs excerpted:

I ask the questions still unanswered. "Is the DNR in effect now? In case of heart arrhythmia, can I give her a shock or more chest compressions? Given the sedation, it won’t hurt." ... Without dialysis, she is doomed by tomorrow. The members of the intensive care unit (ICU) team, having heard about the DNR, are reluctant to treat aggressively. Talking with the family, they are painting a bleak and—to their credit—often realistic picture of what it’s like for someone dying over weeks as organ systems shut down one after another... I’ve resuscitated many patients who died hours later. This case feels different to me. Hopeful. I report my findings to the family. There are times when giving hope is morally and professionally wrong because the hope is false. Today is not that day.

"I think there’s a good chance she is fixable in the short term," I say. ... The family members spend the next two hours in discussion with the primary oncologist, nephrologists, and the ICU team. They decide on comfort care only and no dialysis.

I see the burnout in their eyes. Their will to fight quit weeks ago, after this patient’s minor symptoms from the chemo and cancer were left unaddressed, leaving the impression that her life wasn’t worth living. No amount of hope in my heart can rekindle what has died in theirs.

She is taken off the ventilator and placed on the time-honored morphine drip—a solid choice by the ICU specialist to comfort what comes next. She expires peacefully several hours later from hyperkalemia caused by kidney failure that would have been so easy to treat with dialysis. The best resuscitation of my career turned into my most memorable professional disappointment. It also reminded me that the concept of DNR, however ethically sound and well conceived, can be complex and contentious.


I can appreciate the intent. It's fun to be contrarian and to take on the sacred cows. It's fair to challenge the conventional wisdom that DNR can equal "Do Not Treat." It should not. But the tone of the physician in this case strikes me as highly inappropriate. He clearly has an opinion, as do we all, about what is possible and desirable in a certain clinical situation. That's unavoidable. He understandably is invested in the patient whose life he has extended, at great effort. But Dr Veysman's error here is projecting his own values, his own desires, his own mental status onto the patient and the patient's family. He betrays his bias with the first question he asks -- "Can I give her a shock?" Consider that "Can I?" -- he wants to, he thinks he should, and he is asking for permission. He supports his request with a promise that it won't hurt, which is true. He has crossed the line from an interrogator to an advocate. What he fails to ask is "Should I?" On a broader note, he fails to ask "What would she want us to do?" Rather, he has chosen the course of action which he wants, and he campaigns for this treatment, in spite of the patient's previously expressed desires to the contrary.

Moreover, the author makes some dramatic assumptions about the mental status of the patient and the family, the perceived burden of her disease, and their reasons for making the decision to accept her natural death. He thinks she is not ready to die, but he knows nothing of whether she felt she was ready to die, and whether her reasons were valid. There's even an implication that her situational depression over impending death should have been treated with antidepressants, as if one's looming mortality is a chemical imbalance which must be ameliorated before it can be allowed to come to pass. He has hope, and he takes it as -- literally -- a failure that the family cannot be induced to share that hope.

The conclusion is telling, when he considers his own end-of-life desires: "Only after you made every effort to let me be happy and human, ask me again if my life is worth living. Then, listen, and comply. At that point, if I wish to die, let me die." So presumptuous is Dr Veysman that this patient's family failed to do these things that he pressures them towards aggressive treatment, while he himself wants to be allowed to pass when he determines his time has come! DNR for me but not for thee?

I've had patients & families ask for full measures and I have had them ask to cease efforts when I personally would not have made those choices. Respect for the patient's autonomy demands that I do not argue with them over their decision. There's a fine line between ensuring the decision-makers have enough information to make a truly informed decision and advocating for or against a certain plan of action. Dr Veysman flirts with that line as much as it is possible to do in a semi-fictional vignette with a necessarily incomplete reporting of the difficult conversations that must have taken place.

I'm being a little unfair here, because this really is a complex situation distilled into 2500 words. Were I more charitable, I would assume that Dr Veysman couched his recommendations in more neutral language and displayed more respect for the self-determination of the patient, and for the family's intimate knowledge of her situation. But I have a hard time extending the benefit of the doubt when he is publicly arguing that the signed advance directive should be disregarded if the doctor thinks the family isn't hopeful enough.

So, Dr Veysman, I will be happy to comply with your wishes: should you come into my ER, I will tube you and line you and shock you if that is your wish at that time. I hope that if I come into your ER, that you will honor my requests, that you will not bully my family, and that you will not not subject them to a guilt trip for having, in your eyes, given up.

Give them, and me, that much respect.

10 comments:

Susan petry said...

thank you. I awakened to this commentary on NPR the other day. It was my day off-not the way I wanted to start it!
I had very similar feelings about the author's opinion. How the h*ll can he determine that his 2 minute assessment is more valid than the wishes of that patient's family, is what I want to know.
If he wants to play god like that he should be a hospitalist, not an ER doc.

Jeffrey said...

Unfair? Not by half. Reading that essay, you could smell the funk of an over-ripe ego a mile away. If people want to know why medical costs in this country, here's why.

We went through a similar situation with my father-in-law. Fortunately for him, and for us, his physicians were supportive when he made the decision to stop dialysis and the endless cycle of ED visits, admissions, and discharges, each ending with reduced independence and quality of life.

And if Dr Veysman had been around to try and bully my wife into a full code for her dad? He'd have wanted to make sure there was someone around to resuscitate him.

Susan petry said...

just in case you have not seen it

http://www.theladyandthereaper.com/

Anonymous said...

Well put!

Anonymous said...

When I was a student I lost all innocence about this in ICU via three patients. The one I know I won’t forget was changed to full code after having been DNR for a few months right as I was giving interdisciplinary report. The patient had new catastrophic problems on top of the original deadly one. I felt like I was in a horror movie, it was awful. Being a student my mind just couldn’t process this, and I felt in a haze as I helped prep this poor soul for every invasive thing on this earth. I hurried into the room with an armful of bags to hang, and lines to assist in placing. This patient looked at me and smiled - comfortable and resting when I left for report. Did this patient and family really have any idea that this was now going to change? I didn’t sleep at all that night.

-SCRN

pdxrn said...

>The best resuscitation of my career turned into my most memorable professional disappointment.


Its all about him and his ego. Not about the patient and his needs.

Nurse J said...

very well written and well thought out. good job. amen.

Rogue Medic said...

Nicely written.

If only Dr. Veysman's article suggested as much respect for the wishes of the patient as for the pulse of the patient.

Matlatzinca said...

Kudos for calling Dr. Veysman to task.

Walt Trachim said...

Very good commentary here.

I am in agreement with you on your main point, as well as with Rogue Medic on your views. I have some of my own - mostly in the form of questions - found here:

http://manchmedic.blogspot.com/2010/04/dnrs-yes-or-no.html