Thursday, March 31, 2011

Why Do Coffins Have Galvanized Nails?

1. So oncologists won't pry them open to try to give chemotherapy
2. So nephrologists won't pry them open to try to dialyze them
3. So orthopods won't pry them open to try to fix their hip.

Choose one or all of the above.

I only read the National Post when somebody leaves it around and I am really bored, however this is quite interesting in a depressing way of course.

This of course reminded me of where I trained. We had an oncologist who liked to give his last dose of chemo in the morgue. This combined with the lack of balls of our intensivists meant that on occasion half the ICU were patients with terminal cancer. Our local nephrologists weren't much better.

I had to do 6 soul-destroying, spirit-breaking months of internal medicine during which I had to deal with quite a few of these dilemmas. At that time the older people I was seeing tended to have had large numbers of children. I observed a truism: the children who still lived in the area and had cared for their parents tended to be quite reasonable about extraordinary measures; the children who had moved away were usually very unreasonable and wanted everything done. I am trying to think of an exception to this but I can't. There were as in this case, more malevolent motives

My son is studying bio-medical ethics which for some reason doctors don't have to study. I told him my simple ethics test: "Don't do anything to a patient you wouldn't do to yourself or to a member of your family." A little simplistic, however I have applied it retrospectively to most of the ethical situations I have found myself in over the last 29 (!) years and it seems to more or less work for most of them. (Abortion is an exception; I believe in abortion, some doctors don't) Many times of course what I would do if it were me is not necessarily what the patient wants or more frequently what the family wants but I think if I or preferably somebody else actually sat down and gave the hard facts, I think a lot of people would come around.

The thing is, judging from my coffee room conversations with other doctors, most of them don't want aggressive measures should they have some horrible terminal disease or for that matter some horrible injury that leaves them with a diminished quality of life. Granted I don't drink coffee with a lot of oncologists or nephrologists. With these beliefs however we submit our patients to weeks to months of what must be living hell in the belief that that is what they want. As I mentioned a long time ago one of my least favourite things to hear a surgeon say is, "I don't want to do this case but the family is insisting on it."

Part of my job now as Site Leader is to sit on a QA committee with the Chief of Surgery and some high powered nursing administrators. Some time ago we had a unfortunate (maybe not) 95 year old drop dead in our recovery room after his IM nailing. He had a DNR order which the anaesthesiologist quite correctly respected. Cases like these are always interesting because by hospital policy DNRs are suspended when a patient comes to the OR. The correct response here would then have been to pound on his chest for some time. Nobody was critical of how the case went down, the reason I presented the case was to ask the question of whether it was even appropriate to try to fix his hip and if so could it have been done in a simpler fashion than the gamma nail, which is the method du jour of fixing hips now, especially as his demise was probably due to a marrow embolus from the IM nail.

We seem to get into a few dilemmas like this in our like OR as we do a steady number of IM nails for pathologic fractured femurs. These have a significant incidence of tumor embolism which is almost always universally fatal. This has lead to complaints against members of our department for both over-rescuscitating and under-rescuscitating depending on the attitude and the grief of the surviving relatives. A lot of this could be avoided by having the orthopod actually talk to the family but hey, these are orthopods.

Aside from the ethical issues involved here the article points out that there are financial issues in play as well with a significant amount of health care dollars going into the last six months of care. Of course we all know what happened when they tried to talk about this in the US. Death panels anyone. Sounds like a plan.

1 comment:

burnttoast said...

I believe if the overaggressive family members had to pay 10% of the costs they would totally change their tune. "I want everything done for Mama!"(as long as someone else is paying for it). It is lovely to watch 50+ years of dysfunctional family interactions replayed in the time the surviving parent most needs for the adult children to BE ADULTS not children reliving sibling issues.
And the only tattoo I would consider is DNR across my sternum