It’s harder to keep the patients alive after they’re dead

The question came up to me

About patients, who number three.

Should we try to restart

A non-beating heart?

Or perhaps just them be?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

Today I wrote Do Not Resuscitate orders for 3 hospital patients.

Television and movies thrive on the tension of cardiopulmonary resuscitation (CPR): doctors shout, orders fly through the air, the seconds tick while a life hangs in the balance, and in the end the dead come back to life. In Hollywood, CPR always works.

In real life, CPR patients rarely make it out of the hospital. The ones who have the best chance are the ones who didn’t have much wrong to start with: the young, the athletic.  Those with a tenuous hold on life, the ones most likely to have their hearts stop, do not do well.  Perhaps a third of those with cardiac arrest survive what the doctors call the code.  Most live long enough to generate six- or seven-figure medical bills, but die before they leave the hospital.  And lack of oxygen leaves many survivors with permanent brain damage.

New Zealand’s national policy, when I worked there in 2010, held that age greater than 75 constituted an absolute contraindication to CPR.

Now when I have an end-of-life conversation with a patient or a medical Power of Attorney (POA), I ask, “If your heart stops beating, do you want us to try to restart it?” always prepared for a long answer. Nobody gets to the end without a really great backstory; those who love the frail unambivalently need much less time than those with mixed emotions, and the human condition results in contradictory feelings.

A negative answer comes rolled in with long justification.

For a positive answer I have to explain what CPR and shocks do.

The act of pressing on the chest to keep the blood circulating breaks ribs in everyone over the age of 30, and almost everyone over the age of 20. Electric shocks hurt, and the shock of the defibrillator hurts worse than any shock the average American has ever felt.

Then I get to the question of the tube in the windpipe, which requires unconscious ness and eventually a ventilator.

Few of those born before WWII who retain all their faculties choose resuscitation after my discussion.

None of the patients during today’s discussions wanted CPR. Each conference took a long time.  But trying to rush such a talk is rude and disrespectful, and hurrying it can obscure patients’ real wishes.

So I gave my complete attention, easy when listening to wonderful tales, stuff I couldn’t make up.



Tags: , , , , , , , ,

2 Responses to “It’s harder to keep the patients alive after they’re dead”

  1. Jonathan Taylor, DO Says:

    Some patients literally freak out or the family does when this topic is broached, so I usually start the conversation with a statement that my goal is for them to get better, but if they don’t and get worse then what do they want done. This makes them less stressed and I also state that this is standard on all admissions to the hospital (every one has a order on the template).

  2. walkaboutdoc Says:

    Some freak out, but some are grateful for the conversation.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s

%d bloggers like this: