"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.