"Slow and Show" CPR: Patient's Best Interest?

Cardio-pulmonary resuscitation (CPR) is the term used to describe the action of attempting to prevent a patient from dying from sudden stopping of heart beat or breathing.  CPR has been an accepted medical technique for decades and has been performed both on the outside and inside a hospital.  Within the hospital, it has been the policy over the years to provide CPR to all patients suffering cardiac or pulmonary arrest with few exceptions unless the patient has previously requested "do not resuscitate" (DNR) and this request placed as a physician's order in the patient's chart. 

Since, the time available for resuscitation to begin and have any chance of being effective and prevent death is only a matter of a few minutes at the most, CPR activity must begin promptly with a planned resuscitation protocol including the identification of a cardiac and/or pulmonary arrest event, arrival of medical personnel with necessary equipment and the prompt initiation of resuscitation actions by the staff with appropriate modifications depending on the patient's response.  Though not all resuscitation attempts are successful either to save the patient from death at the time, prevent persisting damage from the event or permit a live discharge from the hospital, without prompt and proper management, death will be the result.

Since CPR has been granted as default to all patients except those who have requested DNR there will be patients who arrest and thus a candidate for CPR who have terminal illnesses with no chance of a valued recovery even if death at this point is prevented.   But the question is "whose value?"  Should it be the determination of the medical staff or should it be that of the patient?  And when there is no DNR requested by the patient either because the patient wanted CPR or that the patient was not offered that alternative, should the medical staff be as energetic in initiating and performing CPR in a patient who the staff assesses as already terminal with unlikely long term benefit from that resuscitation attempt? 

Over the years of CPR, there has been a practice which has occurred in hospitals in which the medical staff having made their own prognosis of a futile life if the patient survives and may decide to not arrive as promptly as necessary to the stricken patient's bedside and when finally starting a CPR activity fail to perform it in an energetic fashion necessary for attempted benefit.  These responses have been titled "slow code" or even "show code" (only "showing" that something was being done but not really doing it with the goal of success.)  This practice has not been institutionally or professionally accepted over the years but is most likely still being carried out.  Why?  It is because since CPR is the default action in hospitals for all patients except those with a DNR order, there will be a number of patients who carry a poor overall prognosis and there will be physicians and nursing staff who recognize this and  find it difficult to be more energetic toward these patients in response to an arrest.  The ethical issue is whether this response by the professionals is really in the overall best interest of their patient or whether the patient should have had an opportunity to make their own informed decision in advance and that decision fully, completely followed by the staff irrespective of the professional prognosis.

The other, alternative approach to encourage patient decision-making would be to completely reverse the hospital policy: all patients and families would be notified on admission that CPR is no longer offered as a treatment unless specifically requested by the patient. There will be no DNR request needed. After all, CPR was originally begun as a treatment only for those in good health but with a sudden unexpected loss of heart beat or respiration through an accident such as electric shock or drowning.

What do you think about the CPR-DNR issue for hospitalized patients and about any persistent practice of "slow" or "show" codes?  ..Maurice.

Patient Refusal to Leave the Hospital: And Now What?

The hospital and the life there leads to sometimes different views among patients. Most patients want to "get the job done" whatever the reason for admission was and what procedures were carried out, to feel better and get on the road to complete recovery and then once the "job was done" to be discharged. There are some patients who for one reason or another want to leave the hospital prematurely "against medical advice" and will get up and leave, maybe without even giving the medical staff an opportunity to offer some final instructions. And then there are the small group of patients, for various motivations either understandable by others or not, who have decided not to leave and refuse to leave the hospital when they can be safely discharged by their physicians and are told it is time to leave.

The physicians, nurses and hospital staff are faced with a dilemma of a patient refusing to leave regarding how to professionally, ethically, humanistically get the patient out of the bed, out of the room and out of the hospital when no further hospital treatment is necessary and there are other patients needing hospitalization and a hospital bed waiting in the emergency room for admission.  For the professionals, this demand by the patient to remain a hospitalized patient against recommendations for discharge is frustrating, emotionally upsetting and presenting uncertainty as to how to handle the situation.

I present this real hospital dilemma to you, my visitors, to get your take on this variation of patient behavior and how you, speaking from the point of view of a patient, not part of the hospital medical staff or administration would handle it.  Any suggestions? ..Maurice.

Graphic: From Google Images and modified by me using ArtRage and Picasa3.

Patient Modesty: Volume 51

It is all about "spreading the word".  In all of these  previous 50 Volumes and literally thousands of postings on this blog, the observations of visitors regarding the inadequate state of preserving patient modesty by the medical caregivers  have been amply described and rarely, if at all, argued against.  It is my opinion that it is well past the time to proceed and, if the "word" is important and vital, to begin to  spread the word to the general public and, of  course, to the medical system itself. 

Not seeing any significant public activism about this issue by my visitors,  I have put up on one internet petition site http://www.thepetitionsite.com/799/493/745/medical-care-providers-must-attend-to-patient-modesty-issues-and-provider-gender-requests/ a statement expressing my summary of all that has been written on this Patient Modesty thread.   Currently, the petition is not drawing much response of support by the public in terms of signing the petition.  Obviously, this petition requires more publicity.  In fact, the writing of perhaps even more  descriptive and emotional petitions on other sites or publicizing the current site would be more effective to gain signatures than my simple summary .

I hope this Volume 51 of Patient Modesty be used as a communication site for the visitors to focus on their own "spreading the word" both through petitions and other means.  If you want change, start it now!  ..Maurice.

Medical Mistakes: The Patient as "Whistleblower" Reporting to the Government

The United States federal government in an attempt to prevent medical mistakes is considering a pilot program which will analyze these mistakes by doctors, pharmacists and hospitals. Medical mistakes not only can unnecessarily harm patients but end up costing everyone including the government money.  The interesting part of the program is that it  will be the patient (or, I suppose, also the patient's family) who will be the "whistleblowers" and notify the government of a suspected mistake.  To get an idea about the program read about it in a recent article in the  New York Times from which a few extracts follow. 

                                                      

  For each incident, the government wants to know “what happened; details of the event; when, where, whether there was harm; the type of harm; contributing factors; and whether the patient reported the event and to whom.”The questionnaire asks why the mistake happened and lists possible reasons:¶ “A doctor, nurse or other health care provider did not communicate well with the patient or the patient’s family.”¶ “A health care provider didn’t respect the patient’s race, language or culture.”¶ “A health care provider didn’t seem to care about the patient.”¶ “A health care provider was too busy.”¶ “A health care provider didn’t spend enough time with the patient.”¶ “Health care providers failed to work together.”¶ “Health care providers were not aware of care received someplace else.”A caution as noted in the article from an official of the American Academy of Orthopedic Surgeons:“However, patients may mischaracterize an outcome as an adverse event or complication because they lack specific medical knowledge.“For instance, a patient may say, ‘I had an infection after surgery’ because the wound was red. But most red wounds are not infected. Or a patient says, ‘My hip dislocated’ because it made a popping sound. But that’s a normal sensation after hip replacement surgery.” [Thus] it was important to match the patients’ reports with information in medical records.

                                                                                         

What do you think about you becoming the "whistleblower" to notify the government when you suspect your doctor made a mistake?  ..Maurice.

Graphic: From Google Images and modified by me with ArtRage

Doctors Maintaining "Clinical Distance": A Patient Value or None

The doctor looks at the patient who

Sits restlessly, coughs and is not smiling

The doctor's first thought

"Why is this patient coughing?"

Instead of

"This patient appears uncomfortable,

What can I do or say to relieve the discomfort?"

+++

What I have just described is a simple example of the professional behavior or perhaps misbehavior of maintaining "clinical distance".  It is the mindset of a technician to immediately look at the anatomy and pathology of the patient's symptoms rather than to look at the patient. Shouldn't the doctor's first interest be the observation and consideration of the patient as a whole human person who comes for consultation because of a personal problem and attempt to understand how the patient is feeling? But the fear of being contaminated by the patient's "feeling" may be more in the mind of the doctor than being exposed to whatever bacteria or viruses the patient is bearing and has become the basis for maintaining "clinical distance"; not measured in meters but in pain, in sorrow, in anxiety and fear.

But, shouldn't, at first, the doctor be more than a technician in the diagnosis and treatment of illness?  Shouldn't the doctor at first find and express some signs and acts of partnership with the patient's worries with responses of sympathy ("I care") and/or empathy ("I understand")?

In the current rush of medical practice where time is limited to attend to each patient and the fear by doctors of "becoming too emotionally involved" (contaminated), it is considered a wise practice to maintain that "clinical distance".  But is "clinical distance" really what makes a good medical professional? Does it provide a way to maintain physicians in less emotional distress, fatigue and more time to diagnose and treat and thus is of benefit and value to the patient?

On the other hand, maybe it is the basis of why some patients are dissatisfied with their doctors in many ways. Perhaps, we medical school teachers should more strongly emphasize to the students something more than the creation of a differential diagnosis list as the doctor-patient relationship begins and strive to shorten that "clinical distance". 

What is your opinion about maintaining vs shortening "clinical distance"?  Should the following be the doctor's first thought?

+++

The doctor looks at the patient who

Sits restlessly, coughs and is not smiling

The doctor's first thought

"This patient appears uncomfortable,

What can I do or say to relieve the discomfort?"

..Maurice.

Prohibition of Abortion in Rape: Who is Responsible for the Outcome?

Particularly these days, as a Presidential election is nearing, the politics of abortion is now in the forefront though it always has been a political and religious issue. Even, from an ethics point of view, the debate has been engaged as to whether a fetus was a person and what ethical, if not legal, rights was available for the fetus.. The issue of abortion is usually associated with either disease or injury on the part of the mother or in the case of an unwanted, unintended pregnancy.  Another area for consideration of abortion is in the case of rape with an associated pregnancy. Should abortion be an option for the mother if pregnant as a consequence of rape? There are political and religious views which deny such an option for the mother since rape should not lead to the punishment of the fetus for such a criminal act. Yet, one can argue that if the fetus of rape is unwanted by the mother and even by the rest of the family and abortion is not an option, who will be responsible for the continuing of the pregnancy and who will be responsible for the further life of the child when it is born?  Some might consider if the responsibility is put on the mother and family that this is simply an ongoing punishment of the mother and family for a crime they did not commit. If the rapist is not the one to assume the responsibility for the result of the crime, do the politicians and religions and others in society who hold that abortion is not acceptable in such a pregnancy, agree that then they are all responsible for the consequences of their dictum including the ongoing management, care and expense of the product of the rape?  Making political, religious or ethical decisions and failing to be responsible for the consequences should be open to scrutiny. What do you think?  ..Maurice.

Patient Modesty: Volume 50

This graphic modified by me from the graphic in an article in the July 30, 2010 New York Times sets an area of discussion on this Patient Modesty thread which we should settle by some consensus.  Those with such intense physical modesty concerns that would interfere with an efficient medical workup and treatment have been, after reading the responses to this thread, in my mind statistical outliers since I never have experienced such patients in my years of medical practice.  OK..that's one potential outlier. The other is the group of healthcare providers who have shown by their behavior and in many ways sexual and dominating actions creating emotional harm of their assigned patients.  I suspect (and hope) this group of providers are also statistical outliers.  I am not saying that such outliers whether patients or providers should be ignored but I think we must appreciate the majority of patients and providers who continue to attempt to improve health and service and not generalize the behaviors of the outliers to the entire population.  This is the topic that I would like further discussion upon as characterized by this Volume's graphic. ..Maurice.

NOTE: FOR THOSE VISITORS WHO HAVE NOT AS YET READ VOLUME 49 AND WOULD LIKE TO DO SO FOR CONTINUITY  (BUT NOT POST) MAY GO THERE WITH THIS LINK.

ADDENDUM; AS OF SEPTEMBER 10 2012, I HAVE STARTED A PETITION SIGNING DRIVE ON
ONE OF THE FREE PETITION WEBSITES TO ACCUMULATE SIGNATURES TO SEND TO THOSE OF RESPONSIBILITY IN THE MEDICAL SYSTEM REGARDING THE ISSUES AND CONCERNS AS PRESENTED IN THESE 50 VOLUMES OF PATIENT MODESTY. IF YOU WISH TO PARTICIPATE, GO TO THE FOLLOWING THEPETITIONSITE LINK.
http://www.thepetitionsite.com/799/493/745/medical-care-providers-must-attend-to-patient-modesty-issues-and-provider-gender-requests/

Graphic: see above linked source.

NOTICE: AS OF TODAY OCTOBER 14, 2012 "PATIENT MODESTY: VOLUME 50" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 51 

"No.. Not Yet":Answering the Patient's Request for "Off Label Use" of a Drug

In the United States, physicians can legally write a prescription for a drug to be administered to a patient with a disease not approved by the Food and Drug Administration (FDA) for use, so-called "off label use" if that drug has already been approved for use by the FDA  for some other disease.  Often, patients and their families faced with a serious disease and unresponsive to any beneficial action by the available drugs for that condition may, after learning from the media of "promising results" from preliminary drug studies for that disease insist that their physicians prescribe that drug.  The "promising results" may be more supposition based on elementary animal studies of the patient's disease and not as yet studied in humans with that disease.  Yet, such "results" are readily documented by the media and thus available for the public to consider and desire.

Physicians practice under the ethical obligations of their profession to be beneficent in their actions with the patient and to avoid harm.  Such beneficence would include to attempt to attain a goal of "cure" for the patient's disease.  But what if the "cure", at present, was only theoretical and not documented by valid testing in humans?  To "avoid harm" is another matter of concern since if approval of the drug was carried out in studies or experience with a disease other than that experiencing by the current patient, can the physician be sure that the drug will be equally safe?

The ethical issue is how should a physician respond to a vigorous and understandable request by a patient or family member for the doctor to prescribe a drug as "off label" for a critical illness, not responding to prior drugs, but a drug which has not been approved by the FDA for such use and whose benefit/safety value for that disease has not been proven but only suggested by the media?

Should what is read by the public on a website or newspaper or heard on TV be something to challenge the doctor?  And does the doctor have the time, knowledge and ethical strength to defend any refusal to follow the request and finally say "no.. not yet."  Or at a certain end-point of an illness, the refusal itself is unethical?   ..Maurice.

p.s.- For more on this topic: "The Ethics of Early Evidence---Preparing for a Possible Breakthrough in Alzheimer's Disease" by Lowenthal, Hull and Pearson in the Perspective Section of August 9 2012 issue of the New England Journal of Medicine.

Graphic: My photograph of medicine bottle and modified with ArtRage and Picasa3.

Refusing to Cast a Deaf Ear to the Ethics of Maintaining Deafness within a Deaf Family

You may not be affected by this topic but as one interested in the ethical issues within society, it is important that you don't ignore and cast a deaf ear on an ethics topic that relates to behavioral actions of other cultures attempting to maintain uniformity and comfort.

There is a view in the culture of the Deaf to maintain deafness within the deaf family. The options, which have been proposed in the literature  to accomplish this cultural requirement would be to 1) prior to implantation of a preserved embryo to first determine whether it had the genetic makeup to be deaf and, if so, proceed with implantation and 2) have the mother take a toxin during a normally started pregnancy to cause the fetus to be born deaf.  Of course, there is a third option: for the family to adopt a deaf child into that deaf family.

So without casting that deaf ear to this topic, do my visitors agree that there is nothing unethical in the culture of the Deaf to maintain that culture by acquiring a deaf child?  If the goal of maintaining the culture is ethical, then about the options presented, would my visitors consider them all ethical to meet that goal? If not, which ones and why? I will be interested to read your opinions.   ..Maurice.

Is Current "Teaching" Medical Students Really "Preaching" to Medical Students?

You know, I was thinking, medical school is all about preaching to the students their Commandments toward their future practice of the profession of medicine.  We are saying to them:
1. "Here are Your Tools for practice We have Chosen to be Given to You, Here is Your Medical Education We have Devised, Here are Your Standards of Practice
2.Here are Your Codes of Ethical Practice
3.You will be Monitored by Us to Graduation and by Others beyond for adherence to Continuing your Medical Education 
4. Your Adherence to Standards of Practice and Codes of Ethics
5.You may Select a Specialty of your Choosing and Comfort but Monitoring for Your Adherence will Continue." 

And if that isn't Preaching the gospel of Medicine, I don't know what Is? 

Should we, in medical school education, really be teaching students only about the options available for taking a history, for performing a physical exam, for making a diagnosis, for providing treatment and for the overall practice of medicine including the pros and cons of various behaviors within the responsibilities of a medical doctor rather than be setting a series of medical rules which have been carried down from one medical generation to another without empiric, statistical documentation of the value or harm of each dictum?

What do you think?  ..Maurice.

Graphic: Preaching from Fellowship Room via Google Images.

   

"The Truth, Whole Truth and Nothing But.." Followed by Words of Comfort

Now here is an Essay from the Hastings Center Report July-August 2012 issue which you can read free and in full by clicking on this LINK which I think brings out a modern and perhaps a common behavior by physicians which clearly is of ethical importance and should be considered by all patients.. The Essay, titled "Comfort Care as Denial of Personhood" by William J. Peace starts with the following abstract.  


Comfort care is an ethical good for the patient but should not be used to meet the needs or frustrations of the healthcare providers. Read the Abstract below but then go to the Essay LINK and read the entire Essay. Then return here and present your comments. Do you think that a physician's suggestion for "comfort care" could be premature and actually be an ethical wrong for the patient? ..Maurice.








 ABSTRACT

It is 2 a.m. I am very sick. I am not sure how long I have been hospitalized. The last two or three days have been a blur, a parade of procedures and people. I had a bloody debridement for a severe, large, and grossly infected stage four wound-the first wound I have had since I was paralyzed in 1978. I know the next six months or longer are going to be exceedingly difficult. I will be bedbound for months, dependent upon others for the first time in my adult life. As these thoughts are coursing through my mind, a physician I have never met and the registered nurse on duty appear at my door. As they put on their gowns I am weary but hopeful. Surely there is something that can be done to stop the vomiting. The physician examines me with the nurse's help. Like many other hospitalists that have examined me, he is coldly efficient. At some point, he asks the nurse to get a new medication.
What transpired after the nurse exited the room has haunted me. Paralyzed me with fear. The hospitalist asked me if I understood the gravity of my condition. He grimly told me I would be bedbound for at least six months and most likely a year or more. That there was a good chance the wound would never heal. If this happened, I would never sit in my wheelchair. I would never be able to work again. Not close to done, he told me I was looking at a life of complete and utter dependence. He went on to tell me I was on powerful antibiotics that could cause significant organ damage. He informed me I had the right to forego any medication, including the lifesaving antibiotics. If I chose not to continue with the current therapy, I could be made very comfortable. I would feel no pain or discomfort at all. Although not explicitly stated, the message was loud and clear. I can help you die peacefully.

Which Direction is Ethical? Should We Simply "Count the Cars"?

My question for this thread is who should set ethics? Who should establish "what is ethical and what is not"? Should it always be society as a whole to establish which direction is the right ethical direction with the decision based on observation of which direction the majority of society is moving?  Or is "what is ethical and what is not" really not a matter of statistics but should be decided upon independent criteria and beyond simply observing the direction set by the general public?

If so then should the decision  be based on what philosophers or other "thinkers" have set in the past and then carried on to the present and the future? In other words do ethical actions and behavior really change over the years? Or if they can and do change should what is ethical be based on how current philosophers look at current issues? What should be the role of religions to establish what is moral and what isn't? Are the religions and their members really the ones to define what is or is not ethical? Finally, should we disregard society, philosophers and religions and say that what is "good" and what is "bad" be defined only by those who are directly involved as actors or recipients in any activity or behavior?  Should it be only the participants who set the ethical standards. 

Who do you want to tell you what is ethical and what isn't? ..Maurice.

Graphic: Photograph taken by me today of the 405 Freeway in Southern California

Failure to Use the Anatomic Names for Female Genitals: Ethical Illegitimacy?

I was a bit surprised and perplexed when I found and read an Essay in the current May-June 2012 issue of the Hastings Center Report, one of the major ethics journals.  Sarah Rodriguez and Toby Schonfeld wrote the Essay titled "The Organ That Must-Not-Be-Named: Female Genitals and Generalized References". It is all about the observation that in various public presentations, the vagina is referred to as "it"  or  "the v" or the female genitalia, presumably the vagina, as "down there" and failure to specifically name the vulva,clitoris, mons or the vagina itself.

My concern with the Essay is whether this is really a vital ethical issue and whether TV's hiding the anatomic names from their advertisements of women's products is worth an ethical dialogue as hoped for by the authors in their final paragraph excerpted here: "Our purpose is to encourage not a monologue about the vagina, but rather a dialogue. Part of this discourse involves recognition on the part of women, men, their doctors, and advertising companies that female genitalia, like male genitalia, are multiply constituted, diverse, and, of necessity, named. We must start using words like vagina in order for the words to become normalized and for the speakers of the words to be empowered and respected—something Betty Ford did for “breast” in the 1970s."


I think there are so many more significant ethical issues around us in this world and the way humans are treated that printed space and reading time should be better applied to them. Go to the link above and read the free full Essay and then return and share your opinion regarding my concern.  Oops! Well, I guess we will have started the authors' dialogue.  ..Maurice.


Graphic: Image from Wikipedia modified with Picasa 3.

Doctor Spying on a Patient's Blog

How would you feel, as a patient, if without your knowledge, your doctor found your blog and was monitoring it for additional information about you?  If you would be upset about that, why? If the doctor told you in advance that he or she was going to look but asked your permission, how would you respond? Do you think that your doctor has every right to look at your open blog as any other visitor? Do you think that your privacy is being intruded upon by the doctor looking at or following your postings on your blog? Would it make any difference if you had a mental illness and your doctor was your psychiatrist? 

In the June 2012 issue of the American Medical Association's Virtual Mentor, the topic of psychiatrists monitoring their patients' blogs is brought up with a scenario and followed by a commentary by psychiatrist David H. Brendel, MD, PhD under the title "Monitoring Blogs: A New Dilemma for Psychiatrists". The first paragraph of the commentary follows.  Go to the link above and read the entire article and then return and answer my questions. Your responses will be worth while to this topic since Dr. Brendel can only express his concerns speaking as a psychiatrist but you can provide feedback to us from any patient's point of view. ..Maurice.

Internet technologies in the twenty-first century have provided countless opportunities and potential pitfalls for professional practice in areas as diverse as medicine, law, politics, business, and academia. These technologies have especially serious implications for psychiatry, where emotional complexities, boundary issues, and privacy concerns are of particular concern in the relationship between clinician and patient. In the course of routine clinical practice, psychiatrists nowadays must grapple with questions about whether to exchange e-mails with patients, to participate in social networking sites such as Facebook, and to perform Internet searches in order to learn information about patients. Each of these uses of Internet technologies in psychiatry has received growing attention in the professional literature [1-3]. The case scenario raises the question of whether clinical psychiatrists ought to read and monitor the websites or blogs of some of their patients.

Graphic: From Colocation America. com via Google Images.

Bad Smell vs Good Smell: Can the Smell of a Decision Determine Its Ethics

 

In life, most of us can smell and make some
interpretation of the source and significance
of the smell. The odor may often be the 
first sign of something bad such as an un-
expected fire or something good such as 
a favorite pie baking in the oven.


Can we carry the analogy of smell to the interpretation of our initial casual observations or by hearing the explanations by others for the basis of their decisions or actions and then go on to develop a firm conclusion as to whether what was decided or what was done was ethical? Can one "smell" the good and the bad of a decision? And with that smell can we accept that smell as a basis for a conclusion?  Can we accept the smell as the basis for whether or not to further investigate the decisions or actions? A "bad smell" requires a thorough investigation of the facts, whereas a "good smell" is evidence enough of a "good". I would argue that it takes more than the presenting odor to establish any final conclusion. Whether a smell is good or bad, I think is in the nose and mind of the beholder and it takes an analysis of as much of the facts as available to reach a reasonable conclusion about the ethics. I bring this topic up because I think it is very easy and I think it often occurs that we "rush to judgment" about someone's behavior or someones decisions or actions.  Criticism or ethical conclusions without all the facts is unwarranted.  Or, perhaps..our lives are too busy with not enough time or interst to develop the facts and it is just easier to go by our noses. What do you think? ..Maurice.

Graphics:  I photographed the images of the artwork of Francis Xaver Messerschmitt found in the 2009 Auction Catalog of Koller Auktionen, Zurich Switzerland.

Telling Bad News: Should the Doctor "Say It Flat Out"?

In my previous blog threads, the issue of a physician telling the patient "bad news" has been rather fully discussed (see links below to those threads).  It always was and always will be a challenge for any physician to communicate this diagnosis since  often the doctor doesn't know how much and how quickly the patient can understand and accept the information.  It also means that the doctor has to find the right words to be informative, supportive and yet empathetic to what the patient may be about to experience.  In the attached video clip from the John Wayne movie "The Shootist", the doctor played by James Stewart finds this challenge as he must tell the "bad news" word to John Wayne who comes for a consultation.  The confrontation of the news by both parties is beautifully played out in this segment of this movie, which, by the way, has been an educational worthy segment for medical students to review. It shows how the patient helped the doctor with the doctor's first challenge with  the words "say it flat out". What the doctor should say after the diagnosis is revealed is the second challenge in doctor-patient communication. If you were the patient, would you be a John Wayne and have your doctor "say it flat out"?  ..Maurice.

Previous "Telling Bad News" blog thread links:

http://bioethicsdiscussion.blogspot.com/2004/07/telling-bad-news.html

http://bioethicsdiscussion.blogspot.com/2005/08/telling-patients-they-are-terminal.html

http://bioethicsdiscussion.blogspot.com/2005/09/doctors-telling-bad-news-but-there-is.html

http://bioethicsdiscussion.blogspot.com/2005/09/how-to-tell-bad-news-telling-it-first.html

http://bioethicsdiscussion.blogspot.com/2006/08/not-telling-bad-news-ethical-dilemma.html

http://bioethicsdiscussion.blogspot.com/2007/03/telling-bad-news-and-not-walking-walk.html

http://bioethicsdiscussion.blogspot.com/2011/08/how-would-you-like-to-be-told-that-you.html

Video Clip: Downloaded from Turner Classic Movies website.

(A Truism)"If You Can't Leave Your Mark, Give Up": Is Procreation That Mark?

I came upon that classic truism "If you can't leave your mark, give up" and then I wondered about procreation as a way to follow the truism. Is there a human necessity for us to find ways to bring a child into the world in order to leave our mark in the world for the future? Of course, for those who can "automatically" procreate, this may not always be the basis for the creation of an offspring.  But for those who can't have children for one medical or biologic reason or another is this need to leave a mark so pervasive as to encourage the single or couple to attempt procreation through one method or another with the help of fertility clinics and the current science of creating an embryo along with implantation and delivery rather than adopting a child? Is instilling our genes into the genetic pools of the future essential to ensure that our life has left that mark? Is this the basic motivation of those who enter a fertility clinic for help? I would like to read the answers from all my visitors with regard to these questions but particularly from those who have utilized fertility clinics .  ..Maurice.

Graphic: Photograph I took of a wooden bench at Yosemite Falls, Yosemite National Park, CA, June 2012.

Coerced Medical Care: Is That Ethical?

Coerced medical care means that the patient will or is having or has received medical care not by their own autonomous decision but because the legal system has decided, after consultation with the patient's doctors that such care must occur.  Dr. Julie Cantor discusses the matter in a New England Journal of Medicine free full text article in the June14 2012  issue.

The first paragraph sets an example:

Samantha Burton was 25 weeks pregnant when her membranes ruptured. Burton's obstetrician admitted her to Tallahassee Memorial Hospital (TMH) and prescribed continuous inpatient bed rest. But with two young children and a job to consider, Burton found the prospect of a 3-month hospital stay overwhelming. She decided to go home. When she tried to leave, authorities barred her exit.

Go and read the Journal article and then return with you own views regarding such legislative, medical or legal actions taken upon patients.

Under what circumstance do you find that a law or court decision should override any voluntary medical decision by the patient? Is it ethical to deny a competent patient's informed and autonomous decision?  Is there a difference if the issue is regarding a communicable disease versus a pregnancy? ..Maurice.

Munchausen by Internet: Should We Believe Everything Our Visitors Tell Us Here?

On many of the threads on my blog, my visitors describe their own medical conditions and their experiences with the disease and with their healthcare providers. Probably more common, of course, are visitors to online chat or websites which deal with and provide support for specific illnesses and encourage discussion.  The general personal anonymity of the postings encourage free discussion of one's described illness and experience.  Often there may be a outpouring of sympathy by the other participants to the site. Unfortunately, it has been discovered and documented that these personal narratives of one's illness are fabricated by the writer for their own psychological reasons. And this condition has been named: "Munchhausen by Internet". An excellent description  of this behavior is described in the Wikipedia presentation "Munchhausen by Internet" from which the following portions are copied below. Go to the Wikipedia link and read the entire article including noting the resources. What do you see as the ethical implications of such behavior on the internet and the effect of such made-up life experiences might have on large numbers of innocent but ill visitors struggling with their own concerns? ..Maurice.

Münchausen by Internet is a pattern of behavior in which Internet users seek attention by feigning illnesses in online venues such as chat rooms, message boards, and Internet Relay Chat(IRC). It has been described in medical literature as a manifestation of factitious disorder or factitious disorder by proxy.^[1] Reports of users who deceive Internet forum participants by portraying themselves as gravely ill or as victims of violence first appeared in the 1990s due to the relative newness of Internet communications. The pattern was identified in 1998 by psychiatrist Marc Feldman, who created the term "Münchausen by Internet" in 2000. It is not included in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR).
The development of factitious disorders in online venues is made easier by the availability of medical literature on the Internet, the anonymous and malleable nature of online identities, and the existence of communication forums established for the sole purpose of giving support to members facing significant health or psychological problems. Several high-profile cases have demonstrated behavior patterns which are common among those who pose as gravely ill, victims of violence, or whose deaths are announced to online forums. The virtual communities that were created to give support, as well as general non-medical communities, often express genuine sympathy and grief for the purported victims. When fabrications are suspected or confirmed, the ensuing discussion can create schisms in online communities, destroying some and altering the trusting nature of individual members in others.
The term "Münchausen by Internet" was first used in an article published in the Southern Medical Journal written by Marc Feldman in 2000. Feldman, a clinical professor of psychiatry at theUniversity of Alabama at Birmingham, gave a name to the phenomenon in 2000, but he co-authored an article on the topic two years earlier in the Western Journal of Medicine, using the description "virtual factitious disorder".^[2] Factitious disorders are described in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (DSM) as psychological disorders involving the production of non-existent physical or psychological ailments to earn sympathy. These illnesses are feigned not for monetary gain or to avoid inconvenient situations, but to attract compassion or to control others.^[3] Chronic manifestation of factitious disorder is often called Münchausen syndrome, after a book about the exaggerated accounts of the adventures of Baron Münchhausen, a German cavalry officer in the Russian Army, that was written by Rudolf Erich Raspe.^[4] When another person's symptoms are caused, such as a child or an elderly parent's, it is called factitious disorder by proxy, or Münchausen syndrome by proxy.^[5]
Feldman noted that the advent of online support groups, combined with access to vast stores of medical information, were being abused by individuals seeking to gain sympathy by relating a series of harrowing medical or psychological problems that defy comprehension.^[1] Communication forums specializing in medical or psychological recovery were established to give lay users support in navigating often confusing and frustrating medical processes and bureaucracy. Communities often formed on those forums, with the goal of sharing information to help other members. Medical websites also became common, giving lay users access to literature in a way that was accessible to those without specific medical training. As Internet communication grew in popularity, users began to forgo the doctors and hospitals often consulted for medical advice. Frequenting virtual communities that have experience with a medical problem, Feldman notes, is easier than going through the physical pain or illness that would be necessary before visiting a doctor to get the attention sought. By pretending to be gravely ill, Internet users can gain sympathy from a group whose sole reason for existence is support. Health care professionals, with their limited time, greater medical knowledge, and tendency to be more skeptical in their diagnoses, may be less likely to provide that support.^[1][6][7]People who demonstrate factitious disorders often claim to have physical ailments or be recovering from the consequences of stalking, victimization, harassment, and sexual abuse. Several behaviors present themselves to suggest factors beyond genuine problems. After studying 21 cases of deception, Feldman listed the following common behavior patterns in people who exhibited Münchausen by Internet:

• Medical literature from websites or textbooks is often duplicated or discussed in great detail.

• The length and severity of purported physical ailments conflicts with user behavior. Feldman uses the example of someone posting in considerable detail about being in septic shock, when such a possibility is extremely unlikely.

• Symptoms of ailments may be exaggerated as they correspond to a user's misunderstanding of the nature of an illness.

• Grave situations and increasingly critical prognoses are interspersed with "miraculous" recoveries.

• A user's posts eventually reveal contradictory information or claims that are implausible: for example, other users of a forum may find that a user has been divulging contradictory information about occurrence or length of hospital visits.

• When attention and sympathy decreases to focus on other members of the group, a user may announce that other dire events have transpired, including the illness or death of a close family member.

• When faced with insufficient expressions of attention or sympathy, a forum member claims this as a cause that symptoms worsen or do not improve.

• A user resists contact beyond the Internet, by telephone or personal visit, often claiming bizarre reasons for not being able to accept such contact.

• Further emergencies are described with inappropriate happiness, designed to garner immediate reactions.

• Other forum members post on behalf of a user, exhibiting identical writing styles, spelling errors, and language idiosyncrasies, suggesting that the user has created fictitious identities to move the conversation in their direction.^[1]

"Difficult Patient": What is your definition and ARE YOU ONE?

There are a series of articles in the current May 2012 issue of the American Journal of Bioethics which offers perhaps a redefinition of the expression often used in medical practice "the difficult patient". In addition, the discussion also involves how to handle such characterized patients including mediation of the doctor-patient relationship, perhaps formally with the utilization of a clinical ethicist.  The journal articles were all written by  thoughtful professional ethics scholars and although they all, most likely have been or will be patients, I wanted, with this thread, to read how my visitors as patients and "scholars" in other ways, would define or redefine the "difficult patient" in you own terms and then tell us whether you think you are one!  ..Maurice.

Graphic: "Difficult Patient" retrieved from Google Images.

Do You Want to be Autopsied?

Routine hospital autopsies, performed by pathologists, in the past was a not an uncommon result after a patent died in the hospital.  Families were routinely asked for permission for the autopsy.  In recent years, routine autopsies far less frequent.  According to a recent report by the CDC (United State Center for Disease Control) written by  Donna L. Hoyert the key findings were as follows:

• The percentage of deaths for which an autopsy was performed declined more than 50 percent from 1972 through 2007, from 19.3 percent to 8.5 percent.
• External causes accounted for 9 of the 10 most frequently autopsied causes of death.
• The percentage autopsied declined with age after ages 15–24: from 60 percent at 15–24, to 11 percent at 55–64, to less than 5 percent at 65–74.
• In 1972, 79 percent of autopsies were performed for deaths due to disease conditions and 19 percent for deaths due to external causes. By 2007, the respective percentages were 46 percent and 50 percent.
• While the age distribution of deaths shifted to older ages from 1972 through 2007, autopsied deaths were increasingly concentrated in the age groups 1–34 and 35–64.

An autopsy, the medical examination of a deceased person, may confirm clinical findings, provide more complete information to describe cause of death, or uncover conditions not recognized clinically prior to death (1). Two types are performed in the United States: a) hospital or clinical autopsies, which family or physicians request to clarify cause of death or assess care, and b) medicolegal autopsies, which legal officials order to further investigate the circumstances surrounding a death (2). The autopsy rate, or percentage of deaths that received this final assessment, was stable from the 1950s until the beginning of the 1970s, when the autopsy rate began to decrease (3). This report uses mortality data from the National Vital Statistics System (NVSS) over a 35-year period to examine changes in the autopsy rate and in the distribution of those autopsied by age and cause. Variation in autopsy patterns has implications for which deaths may have a more complete and conclusive cause-of-death determination.

Read the full study.  To answer the question, why are autopsies not as popular now as it had been in th past, George Lundberg, M.D. writing in KevinMD suggest the following from the view of each participant except, of course, the deceased patient:

1. Pathologists don’t like autopsies because they can be unpleasant, smelly, time-consuming, unappreciated, often not specifically paid for, and they take time away from other tasks viewed as more important, appreciated, pleasant, and lucrative.
2. Clinicians do not like autopsies because it is uncomfortable to face a family that has lost a loved one. The physician must confront a level of failure because of the death, a tarnishing of the doctor-as-god image. Autopsy surprises might lead to an unhappy family, quality assurance committee concerns, possible litigation, and even a report to the state medical board.
3. Hospital administrators do not like autopsies because they prefer not to dwell on unfavorable results of hospitalization. They claim difficulty finding the money to pay for them and can never make a profit from autopsies. They often have little medical or scientific background that would encourage curiosity and they tend to do mostly what licensing and accrediting agencies require; these remain strangely silent.
4. Third-party payers do not like autopsies because they are an expense, and are performed on people who are already dead.
5. Families of patients do not like autopsies because they are ill-informed about their value, afraid that it might cost them money, and some feel that the deceased person has already been through too much of an ordeal in dying.

The value of any professionally carried out autopsy might reveal not only some unexpected or unknown cause of death but also could provide the medical profession and future generations with knowledge of disease never previously described. In these days of modern technology from MRIs to genetic analysis, there is always room for the old fashioned but information-yielding autopsies. Permitting  an autopsy could be looked upon as a altruistic action for the future living even though, unfortunately, the patients themselves will no longer be benefited. 

So  the question for this thread: "Do you want to be autopsied?" And the answer is:____________. 

(You might also explain your answer.)  ..Maurice.


Graphic: From Wikimedia Commons: "The Anatomy Lesson of Dr. Nicolaes Tulp"  Rembrandt, 1632

Patient Modesty: Volume 49

I think the last two postings on Patient Modesty: Volume 48 set the problem of the current medical system followed by a explanation of why the problem is present.  Both and together I think, are worthy preface to begin Patient Modesty: Volume 49. ..Maurice.

From Anonymous:

As a woman, I've appalled with the way the general medical profession handles (or doesn't handle) patient modesty, and their seeming obsession with having access to the genital area. In the past I have been denied everything from allergy tests to antibiotics for ear infections due to my refusal to submit to a PAP smear. So be it, I now turn to alternative medicine for what I can, and suffer through the rest.
My 60-year-old husband never quite understood my views since he'd only gone for random physicals and never experienced anything untoward. However, he rcently underwent an outpatient surgery to have an ICD device placed in his shoulder, and now he understands. 
He was required to check in to the hospital 2 hours before his scheduled surgery time. A nurse came in and gave him a gown and told him to remove everything including his underwear. She wrote something on a chart and repeated "Now don't forget your underwear." Then she adjusted the bed and a third time said "Remember to take off your underwear." I could tell she was making him very uncomfortable with her repeated focus on his underwear, so I firmly told her to Back Off. I told her he was neither deaf nor mentally impared so I was certain that he understood her directions, and I asked her to leave. She left, but he was visibly shaking as he got changed. And then we sat there in that room for 2 hours, with literally nothing else happening beside a nurse coming in 1 time to take his blood pressure (which was higher than usual). Finally nerves got the better of him, and he slipped his pants back on so he could walk around the room a bit. Like she had radar, a nurse came in shortly after and berated him for not having all his clothes off. So he took off his pants again and laid in the bed for 2 more hours while nothing happened.
Finally a man came in to take him down to the pre-op room. My husband was allowed to go to the bathroom before being wheeled downstairs. And as he asked me, WHY did they insist on him being nude under a butt-revealing short gown for all that time? Could he not have just been told to change when he went to the bathroom? It seemed like nothing more than a tactic to upset him and make him submissive.
Once in the staging area, a nurse cleaned the shoulder area, inserted an antibiotic IV, and jokingly told him not to go anywhere. The she flipped up his sheet a little and joked "Not that you're dressed to make an escape anyway, right?" before she left the room. Wow, what a way to humiliate a frightened man and emphasize his vulnerability. My husband went a little nutters at that point, asking me to remove his IV and bring him his clothes so he could leave. I had to beg him to go ahead with the potentially lifesaving procedure.
Afterwards he was supposed to stay in recovery for an hour (where I wasnt allowed to be)before being returned to his room, but it didn't work out that way. I don't know what happened in recovery, but he came walking up to me in his gown and asked for his clothes. I gave them to him, he changed in a bathroom, and we left.
Now he says that when the battery on the ICD wears out, he won't go back to have it replaced. He says the thing can just "Sit in his chest doing nothing" because it "isn't worth it" to have to go through all that.
Nornally my husband is the apitome of a rational thinker, so obviously their techniques really upset him. I'm sure he wouldn't have made such a rash end decision if they hadn't insisted on making him lay around for 4 hours feeling humiliated with those 2 nurses making an issue of it, when there was no need for it. And they wonder why people don't go in for needed tests and procedures? What's wrong with our medical society?

And from BJTNT:

When you work for the demi-god, you are an angel and patients are mere mortals. This culture has evolved into the PCC syndrome - Power, Control, and Convenience for the medical operations employees. Assume this premise and see how much this describes what you observe in medical operations.
The unfortunate element of the PCC syndrome is that the employees can practive it with impunity. There is no management to crack down on them. The MO administrators are only concerned with implementing the medical committees and ownership policies. The supervisors are promoted employees with the PCC mindset. And MDs only want to "see patients". So, the kids get to run the candy store.
On the other hand, as POGO stated in the Walt Kelley cartoon of the same name "We have found the enemy and he is us." We expect [and I think rightly so] high standards from medical operations{MO} because our health and even our life can be at stake. But, to the MO employees it's just a job. It's just a job with some nice perks {PCC}.
BJT


Graphic: From Google Images and modified by me with Artrage and Picasa3.

NOTICE: AS OF TODAY AUGUST 15, 2012 "PATIENT MODESTY: VOLUME 49" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 50