Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Honoring a Do Not Resuscitate tattoo in an unconscious patient

Also to be posted on ResearchBlogging.org when they relaunch the site.
 

The DNR (Do Not Resuscitate) tattoo is the kind of problem that leads doctors, nurses, and EMS to pretend to be lawyers, lawyers to pretend to be ethical, and patients to be treated against their wishes.

EMS transports a patient to the emergency department. The patient has a chest tattoo of Do Not Resuscitate and what appears to be a signature.
 

Paramedics brought an unconscious 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation to the emergency department, where he was found to have an elevated blood alcohol level.[1]

 

It appears that they have access to the patient’s history, but they do not have information about a DNR in the history.
 

Because he presented without identification or family, the social work department was called to assist in contacting next of kin. All efforts at treating reversible causes of his decreased level of consciousness failed to produce a mental status adequate for discussing goals of care.[1]

 


 

The patient does not currently appear to need an invasive airway, or anything else that would be prohibited by a DNR, so there is time to consult with others.
 

This decision left us conflicted owing to the patient’s extraordinary effort to make his presumed advance directive known; therefore, an ethics consultation was requested.[1]

 

Do we honor the stated, although perhaps not letter of the law until after a court decision, DNR?

If you want to be resuscitated, do not tattoo DNR, or Do Not Resuscitate, on your chest.

But what if he did it while drunk?

There was a case of a patient doing that.
 

When asked why his tattoo conflicted with his wishes to be resuscitated, he explained that he had lost a bet playing poker with fellow ancillary hospital staffers while inebriated in his younger years; the loser had to tattoo “D.N.R.” across his chest.[2]

 


 

They are called Darwin awards for a reason.

Hold my beer and watch this is not usually the start of a tale of wisdom, but of providing a learning opportunity for others.
 

It was suggested that he consider tattoo removal to circumvent future confusion about his code status. He stated he did not think anyone would take his tattoo seriously and declined tattoo removal.[2]

 

After driving to the bar, while sober, an individual decided to drive home, while drunk.

The person should clearly not be held accountable for a decision made while drunk.

A person puts a mask on and uses a cap gun to hold up a store where a friend works, because that kind of thing is funny. Someone calls 911, or . . ., and the humor loses something in translation to reality.

I can be very silly, but I take the wishes of the patient seriously.

If a DNR tattoo was a joke, well, that was may be a bad decision, because you don’t know who is going to be deciding how to treat you when you are not capable of expressing your wishes competently.

The EMS laws tell me that I should always start CPR (CardioPulmonary Resuscitation), while calling a doctor for permission to stop, because the wishes of the patient are less important than the wishes of the doctor on the other end of the phone.

I know too many immoral doctors, nurses, and EMS personnel.

For example, a patient who has a clear DNR, clearly states that intubation is not wanted, but is deteriorating. The doctor occasionally returns to ask the hypoxic patient, Do you want to breathe? The patient keeps indicating that intubation is not wanted. Finally, the patient, through surrender to the harassment or disorientation secondary to hypoxia, says, Yes.

The doctor gets to perform a procedure and satisfy himself that the right thing was done, because it is what the doctor wanted.

Is that an extreme example? It was not seen as extreme a couple of decades ago. Maybe today it is recognized as abuse, because we recognize that the purpose of patient care is to take care of the patient, not the doctor, not the nurse, not EMS, not the supervisors, and definitely not the lawyers.

But you have to obey orders. If the military did not obey orders, we would have chaos.

Even the military does not require that anyone obey any unlawful order.
 

Any person subject to this chapter who–

(1) violates or fails to obey any lawful general order or regulation;
(2) having knowledge of any other lawful order issued by any member of the armed forces, which it is his duty to obey, fails to obey the order; or
(3) is derelict in the performance of his duties;

shall be punished as a court-martial may dire(ct.)[3]

 

Refusing to follow unlawful orders is not easy.

People in EMS will often state that the reason they did something wrong (as in something bad for the patient) is that they did not want to get yelled at by the doctor and/or nurse.

Clearly, our integrity is not what it should be.

Should we only go out of our way for the patients we like? No. My objection to using the guy who obtained the tattoo while drunk, abd does not want to remove it is nothing to do with his drinking or his bad decision, but with his lack of concern for others. My concern is for people who do care what is done to them, regardless of the lack of concern of this uncaring patient.

Of course, the uncaring patient has had the opportunity to have this explained to him and he has decided to live with that risk. He may not have made the best decision, but it is his decision and it probably will not affect him.

But the person with just a tattoo does not have a legal tattoo!

Maybe it is not legal.

Maybe it is legal.

That is for a lawyer to decide.

As the article states, this patient has gone to extraordinary effort to make a statement with this tattoo.

In the absence of something to show that the tattoo does not express the patient’s informed decision, I accept it as expressing the patient’s wishes.

If I am there it is to take care of the patient, not the medical command physician, not the protocol, not the quality control department, not the legal department, not the supervisors, not the doctors, or nurses, in the emergency department, . . . .

When our medical and legal systems are so broken that we feel that we are forced to harm our patients to be able to do our jobs, we need to stop making excuses and start to change things.

Footnotes:

[1] An Unconscious Patient with a DNR Tattoo.
Holt GE, Sarmento B, Kett D, Goodman KW.
N Engl J Med. 2017 Nov 30;377(22):2192-2193. doi: 10.1056/NEJMc1713344. No abstract available.
PMID: 29171810

Free Full Text from NEJM.

[2] DNR tattoos: a cautionary tale.
Cooper L, Aronowitz P.
J Gen Intern Med. 2012 Oct;27(10):1383. Epub 2012 May 2. No abstract available.
PMID: 22549297

Free Full Text from J Gen Intern Med.

[3] UCMJ 892. Article 92—Failure to obey order or regulation.
Uniform Code of Military Justice
Subchapter 10
Punitive Article

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Comment on Why Did We Remove Atropine From ACLS? Part I

 

In the comments to Why Did We Remove Atropine From ACLS? Part I is this from BLS in Wichita
 

Another important question…why are we even attempting resuscitation on many of the patients we encounter in sudden cardiac arrest. Many of these lives are not savable, yet it’s all hands on deck for a wasted heroic effort. We dump tons of resources in to a futile effort.

 

We do.

The AHA (American Heart Association) continues to try to come up with better answers for these problems, but they are often not easy to solve.
 

Shouldn’t we be applying our resources where they are needed most, rather than on an octogenarian with multiple medical problems and stage 4 cancer?

 

That raises some important questions.

If ACLS is for hearts too good to die, then why apply it to people who are dying from other causes?
 

It now seems possible that with an adequate program of prevention, continuous monitoring and with a prompt aggressive approach to the prevention and ablation of serious cardiac arrhythmias, fewer acute coronary patients will be dead with “hearts too good to die.”[1]

 


 

This is from 1967, so there is mythology that has been discarded, such as the need to give atropine with morphine to avoid arrhythmia.

However, they do describe their rate of successful defibrillation to some sort of improved outcome.

What is the improved outcome?

ROSC (Return Of Spontaneous Circulation)?

Survival to non-arrhythmic death?

Survival to discharge?

We do not know.
 


 

13% survival to discharge would be good for 1967, especially since the expected alternative would be death, but is it 13% survival to discharge?
 

One reason we try to resuscitate far more people than just the hearts too good to die is that arrhythmia is not the only reversible cause of cardiac arrest.

Another reason is that we refuse to differentiate between quantity of life and quality of life.

We also are not good at recognizing our limitations.

What about a DNR (Do Not Resuscitate) order?

Some patients do not have the kind of DNR that EMS is permitted to follow, so we are required to call medical command for orders to follow a legal document that says don’t do all of the things that we do.

We can be a very destructive force once we are set in motion, because we are required to do things that we would be prohibited from doing to other people outside of EMS – and we are not good at recognizing this.

Some EMS providers will decide that it is more important that they attempt resuscitation, than respect the legally valid decision of the patient – and EMS rules do not discourage this.

The patient knows why he does not want to be resuscitated, but some of us only respect a patient when the patient makes the decision we want him to make.
 

A couple of EMTs from the local ambulance company responded to a call I was dispatched on for difficulty breathing. The patient was about 50 years old and had a DNR. The DNR did not affect care on that call, but both EMTs (older than the patient) stated that they would refuse to honor the DNR, because He is too young to have a DNR.

We have people who think they are helping, but are making things worse.

These are people who should not be in EMS.

EMS is not about taking care of the patient not taking care of our egos.

If the patient’s wishes do not match our desires, we need to grow up and provide patient care.

Resuscitating an octogenarian is something that is not bad. An 80 year old male is expected to live for 8 more years, while an 80 year old female is expected to live for 10 more years.

Quality of life is important. Having stage 4 cancer and being resuscitated to be able to have another painful death is not good patient care, unless that is what the patient wants.

We need to pay attention to quality of life and patients’ wishes and stop trying to force patients to live according to our prejudices.

Footnotes:

[1] Hearts too good to die–problems in acute myocardial infarction.
Johnson JB, Cross EB.
J Natl Med Assoc. 1967 Jan;59(1):1-6. No abstract available.
PMID: 6038580 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

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The Living Will and Senate Testimony From Terry Read

Terry Read sent me an email with a scan of his father’s living will and a link to the Texas Senate Hearings (the link is also in the comments to Terry Read Comments on the Death of His Father and the Living Will).

Rogue Medic,

I say that I know what happened based on the fact that I was there and went through it.

My point is that this is a very emotional experience. People regularly make mistakes in describing events. For example, in the testimony given by you and by your mother, you contradict each other. Does that mean that one of you is telling lies?

No. It means that our observations depend on many different things, as do our memories.

You are basing your comments on your speculations. So anything that I say certainly has more weight than what you say.

Yet, I can show that your statements are inconsistent, even though I was not there.

Eyewitness testimony is unreliable.

As far as the San Antonio Fire Department not initially cooperating, why do you think this has been going on for so long?

Please provide some evidence to support your conclusion.

You claim that this took a long time. Compared to what?

You claim that the SAFD did not cooperate with someone. Whom did they not cooperate with and what evidence do you have that they did not cooperate?

The investigation took a long time because the Fire Department was not answering the DSHS investigator.

Do you have any documentation to support that claim?

Have you read HB 577. It says “
SECTION 1. Section 166.102(b), Health and Safety Code, is
amended to read as follows:
(b) When responding to a call for assistance, emergency
medical services personnel:
(1) shall honor only a properly executed or issued
out-of-hospital DNR order or prescribed DNR identification device
in accordance with this subchapter; and
(2) have no duty to review, examine, interpret, or
honor a person’s other written directive, including a written
directive in the form prescribed by Section 166.033.”

So Rogue Medic, treatment by the paramedics may still be terminated, but not by not by the Living Will.

That is not true.

EMS may still contact medical command, as they did in the case of your father, and follow medical command orders. Even the person reading the bill in the video states that specifically.

Resuscitators’ efforts can still be stopped if the patient’s personal physician is present and approves it. If the physician is not present, the medical director of EMS can make the decision.[1]

HB 577 does not state that EMS may not honor a living will.

It is offensive that you would prevent people with living wills from having their wishes followed just because of one unusual, but personal, case.

The State EMS Director admitted the person on the other end of the phone may not be a doctor during the House Committee hearing in which I testified.

An out of context description of a comment is useless. What did the person say? What did the person mean? What was the context?

If a movie reviewer describes a movie as “A tremendous waste of time.” Advertisements for the movie could quote the reviewer as calling the movie “Tremendous.”

That would be tremendously out of context and not at all helpful. You misinterpret HB 577, but you expect me to accept your interpretation of something else? Why?

Through the Open Records Act, I have requested minutes of the meeting, but have not gotten them yet. I am not sure how detailed the minutes are. But you are certainly welcome to make the same request. It was the House Public Health Committee Meeting for April 20, 2011 – for HB 577.

That would be nice.

The lead paramedics stated it would be against the law to continue when I told the paramedics not to stop treatment. Then when I tried to get to my father, the paramedics ganged up on me, wrestled me down, and threatened to have me taken away in handcuffs.

Criminal law, civil law, EMS law, company policies, something else?

Plenty of people will tell you that treating a patient in violation of a doctor’s order is practicing medicine without a licence. I disagree with that interpretation of violation of a doctor’s orders, but that may have been what the paramedic meant, assuming the paramedic actually made that statement.

As far as the Living Will, I can ask WOAI to post. But in the meantime, what would you like me to do, scan it and shoot it to you? Would you like me to photocopy it and mail it to you? If you provide a mailing address, I will do that. Would you like to meet in person and have me show it to you personally? If you do, I am sure we can arrange a meeting.

Below is the living will.


This is a scan of Samuel Read’s living will sent to me by Terry Read. I have edited it to remove the Social Security Number and to convert it to JPEG format. Click on the image to make it larger.

But I am a little curious. Will any of this satisfy you? Also, if you watch the story, what do you think that I was showing to Mireyea Villarreal? I was going over the Living Will with her.

How would I know what you were showing her?

Why would I jump to any conclusions about what you were showing her?

If they had the document, competent journalists should have provided at the very least the wording of the document, but that was not done. In the absence of evidence, the most reasonable conclusion is that the document does not support your claims.

You seem to think I have been hiding something when I have not.

I have only been asking for evidence to support your claims and making the most reasonable conclusions about the evidence available.

As far as a patient not wanting resuscitation, they still have the option of a DNR.

The rules affecting advance directives need to be dramatically rewritten.

What you mean to state is that they still have the option of an Out-Of-Hospital DNR.

If they have a standard DNR, which is not an Out-Of-Hospital DNR, the rules are the same as for a living will.

This is abusive and unfair to patients.

You are supporting abuse of patients with wishes different from your father’s.

The link below will take you to the 82nd Legislatures Senate Committee on Health and Human Services Sessions. Our Testimony is on the May 17, 2011 session. HB 577 is the second bill being testified on. My mother and I begin testimony at about the 7:40 mark.

http://www.senate.state.tx.us/75r/senate/commit/c610/c610.htm

You can hear my mother and myself both testify that the Living Will called for examination by two physicians, and my mother had power of attorney. None of those things happened. This is what we testified to before a Senate Committee. Do you think both my mother and I committed perjury?

You and your mother gave different descriptions of the events of that day. Not just slightly different, but contradictory. Does that mean that either, or both, of you committed perjury?

You still do not understand how unreliable eyewitness testimony is. You and your mother were eyewitnesses to the same event and provide descriptions that do not agree.

Do you think that a copy of the Living Will was not supplied to Representative McClendon’s office in their investigation?

Should I assume that Rep. Ruth McClendon has any understanding of advance directives?

Absolutely not. Look at the wording of this bill. This is written so that lawyers will be involved. As I stated before, in Representative Ruth McClendon Trying to Eliminate Patient Rights in Texas,

Also, do you think that the Living Will was not provided to the Department of State Health Services in their investigation?

Did the Department of State Health Services find any fault with SAFD?

Chief Grenato says paramedics on scene reviewed Sam Read’s living will with a medical expert over the phone; then decided to stop treatment. The state has reviewed this case and cleared the department of any wrong doing.[2]

The state has reviewed this case and cleared the department of any wrong doing.

If my mother and I both committed perjury on what was in the Living Will, all of these parties would know it.

Why do you assume that anything that is not perjury is the truth?

You can make the statement that you have not perjured yourself, but that does not mean that what you stated is the truth, the whole truth, and nothing but the truth.

Truth and falsehood are not clear black and white issues. Otherwise, you and/or your mother have perjured yourselves by giving different testimony.

Since all of these parties did not come to the same conclusion, there must be more to this than you understand, which is what I have been stating from the beginning.

For example, let’s compare the testimony given by your mother, where you were not handcuffed and your testimony, where you were handcuffed.

They then threatened to handcuff him and take him away and stated that that would not bother him at all.[1]

and I tried to get to my father to continue treatment myself. They wrestled me down and had me taken away in handcuffs, so I had to give up at that point.[1]

Whom should I believe? Is this perjury? Did you just make a mistake?

The state has reviewed this case and cleared the department of any wrong doing.

Also, note that the State EMS Director was not at the Senate Committee Meeting after having gotten questioned at the House Committee meeting.

OK, but what does that mean? Does it mean anything? Does it signify anything other than the person having limited time and many responsibilities?

One more thing, I am almost 49 years old and have a 4 year old son that my wife and I prayed many years for. And like you, I have other interest as well. Do you think I would have devoted the tremendous amount of time, energy, and emotion to this effort, as I am still doing, if I did not know that the wrong thing had really happened? I have gained nothing from this financially. The only thing I have gained is recognition that the wrong thing happened. And even now, I am still dealing with people like yourself.

Terry Read

I repeat that you are very emotionally involved in what happened and that has affected your actions. I do not know what a daughter, prayer, or time have to do with this. People do plenty of things voluntarily, but that does not mean that they are right. You are comparing things that are completely unrelated.

If the paramedic contributed more of his energy, more of his free time, and spent more of his money contradicting you, would that make him more reliable than you? He was there. What if he has half a dozen children? Would that affect what is true?

On political issues, people on differing sides contribute a tremendous amount of time, energy, and emotion to this effort, but that does not mean that both sides are right, or that one side is right and the other side is wrong.

You ask me to read your mind. Mind reading is what scam artists do. I look at evidence.

Time, energy, and emotion do not determine the truth.

Your justifications only discourages trust in your judgment.

Is it true that EMS personnel are not capable of interpreting a simple document?

Or is it that the lawyers write unnecessarily complicated documents to discourage others from interpreting these documents.

What if we educated EMS personnel (and nurses and doctors) about the application of advanced directives and simplified them. For example, my suggestion for a living will clearly state at the top of the page what minimum requirements need to be satisfied (based on those from Samuel Read’s living will). This is just one possible way of improving the communication of the patient’s wishes.

All of this could have been prevented by requiring that these documents be written much more clearly, not by arbitrarily assuming that more treatment is better.


Click on the image to make it larger.

If EMS is incapable of interpreting well written advance directives, then EMS clearly cannot provide complicated treatments to any patients. The most complicated EMS treatment algorithms are used for treating cardiac arrest.

Should we only provide treatment that is simple and easy?

Would patients be better off with less treatment, so that we don’t have to think? Mr. Read, in his testimony, states that more treatment is better.

That is not true. What we need is more appropriately applied treatment.

Defending the incompetence of the legislature in writing rules for advance directives is not good for patients.

We need to stop lowering our standards to accommodate those who least understand.

Footnotes:

[1] Video of May 17, 2011 testimony
Texas Senate
Page with link to video in Real Media format

[2] EMS workers stop medical treatment after reading will in the field
Mireya Villarreal
July 27, 2011
WOAI
Article

.

Terry Read Comments on the Death of His Father and the Living Will

Over at Medic Madness, Terry Read responds to some of my comments on the handling of his father’s death. Since when is it not our responsibility?

Rogue Medic,
By your definition of “unreliable”, all witnesses would be unreliable. Military people being interviewed on the History Channel about a battle could not be trusted.

All witnesses are unreliable.

It is only by comparing the different descriptions of the same events that we are able to determine what is closest to the truth.

Take a look at the Rashomon effect. The story and film, Rashomon, are 94 years old and 61 years old, respectively. This is not something new. Even ancient Solomon had a memorable way for evaluating the accuracy of witness accounts. Solomon’s sword is memorable, but rarely helpful.

Witnesses are unreliable.

Believe me, I know what happened.

This is what I often hear as justification for not examining facts. Perhaps with an offer to buy something that is too good to be true.

So does the San Antonio Fire Department. That is why they were so reluctant to cooperate with the Department of State Health Services (DSHS) in the investigation.

Please provide some evidence that they were reluctant to cooperate.

In defending the DSHS decision to clear the Fire Department and the Paramedics, The State EMS director said the “policies are locally determined”. Representative Zerwas said “If that is the policy, that concerns me more”.

Yet the law the Texas Legislature passed does nothing that would change what happened.

EMS called medical command. EMS would still call medical command for orders to discontinue CPR in the case of anything that is not a Texas Prehospital DNR. This is the same as the rules in Pennsylvania, which need to be overhauled to prevent patients from being treated against their will.

Representative Susan King got the state EMS director to admit that the person at the other end of the phone may not even be a doctor.

Please provide some documentation to support that claim. If any such statement was actually made, the context in which it was made.

When asked about the paramedics stating that it would be against the law to continue, the state EMS Director said, “that was a misunderstanding”

It may be against EMS policies to continue, but not against criminal law. Did anyone actually state this? If someone did say this, in what context was that statement made?

Also, if you actually listened to my story, you would know that I have stated all along that the lead paramedic went into the other room and got on the phone with someone. Then came out and said “Stop!”. So I never claimed that the paramedics were not in contact with another party. But the lead paramedic did have a key role in interpreting by reading the Living Will over the phone. And obviously he did not read the entire Living Will. Have you gone to the WOAI website to read the Living Will in its entirety?

I have read the full story. I have only seen what you put in the comments. I have not seen the actual document anywhere.

You have demonstrated that you are clearly the one who is unreliable. You were asking why I did not produce the Living Will when I had posted the Living Will on the WOAI website just a couple of days after the story. If you read the Living Will, you will clearly see that the Living Will was not followed.

There is no document posted on the web site, only a comment in which you state that what you are copying is the living will.

It is interesting that you now appear to recognize that a living will is not a will.

Not trusting all of the comments on a story does not make me unreliable. Until I have seen the document, I have not seen the document. You are the one with connections to WOAI. Get them to post it.

That fact alone puts the weight of the evidence on my side.

I could claim that your reluctance to post the actual document does exactly the opposite, but I’ll wait until I can see the actual document.

It is fascinating that when I testified before Committees in both the Texas House and Senate, no one questioned my story.

They are politicians. Their job is to create the impression of reacting to a public interest story.

But you do.

I am not a politician.

I am only interested in improving patient care and in finding out the truth.

I do not know if you are intentionally misrepresenting the events, if your recollection is colored by emotion, or if you are presenting mostly accurate statements.

You really do need to go to the WOAI website and go through all of the postings if you are really interested in the facts, which I suspect that you are not.

Comments on an article are not facts. If you want to provide facts –

Provide a link to a transcript, or other recording of hearings addressing this.

Provide the actual living will to someone who will confirm its authenticity before posting it.


Image credit.

DNR (Do Not Resuscitate) orders are flawed and always will be. We need to encourage those writing the laws to clarify the wording of these documents, not to come up with more complicated ways of presenting them. The Texas legislature passed a law that does not really change anything except to complicate things.

If the Texas (or Pennsylvania) legislature had any idea of what they are doing they would simplify the documents so that a doctor is able to read these documents at a point when time may be critical in determining what to do.

We should not presume that everyone would want to be treated. We should encourage people to clearly express their wishes, so that their treatment follows their wishes as closely as possible.

There will always be cases where things do not go as planned. EMS (Emergency Medical Services) would not exist if everything went as planned. We are the Help, something went wrong with . . . people.

People should not try to change the rules on living wills to invalidate the wishes of all of those who are conscientious enough try to make their wishes known ahead of time.

Representative Ruth McClendon does not appear to have any idea of how to do this, but she did create the false impression of caring about patients’ rights.

Representative Ruth McClendon Trying to Eliminate Patient Rights in Texas

If we want some living wills to be interpreted by lawyers, then we need to have that written in big letters across the top of each page, otherwise it is the job of EMS to contact medical command to determine what to do. If the document is worded to be interpreted by a doctor, then EMS is doing that by contacting medical command.

The legislature is at fault for creating documents that are not easy for a doctor to interpret.

Legislatures exist to write complicated documents that require the interpretation of lawyers, but that is not surprising, sine they are mostly made up of lawyers. They take what should be simple and complicate it.

End of life decisions, CPR/no CPR, intubation/no intubation, blood transfusions/no blood transfusions are going to be different for different people. We need to respect the decisions of those people. We should not impose our wishes on them.

.

Reducing Unnecessary Hospitalizations of Nursing Home Residents


ResearchBlogging.org
Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

Today in the New England Journal of Medicine there is a perspective piece on something near, and dear, to all of our hearts – unnecessary hospital admissions from nursing homes.

A lot of nursing home patients could be treated on site, without calling an ambulance to take them to the ED (Emergency Department) to produce large bill, but maybe not any better care.

More than 1.6 million Americans live in nursing homes. Hospitalizations are common in this population; in 2006, 23.5% of the people admitted to a post-acute-care skilled-nursing facility were rehospitalized within 30 days.1 Several studies suggest that many of these hospitalizations are inappropriate, avoidable, or related to conditions that could be treated outside the hospital setting — and they cost more than $4 billion per year.1-3 Avoidable hospitalizations are also common among long-stay residents of nursing homes (see graphs Unavoidable and Potentially Avoidable Hospitalizations of Nursing Home Residents Eligible for Both Medicare and Medicaid, 2005.).2-4[1]


Click on the image to make it larger.

In addition, nursing homes have a financial incentive to hospitalize residents who have Medicaid coverage, because after a 3-day inpatient stay, the resident may qualify for Medicare Part A payment for post-acute care in the nursing home at three to four times the daily rate paid by Medicaid.4[1]

I knew it.

I knew it.

I knew it.

I knew it.

I . . . .

Two caveats are critical. First, not all hospitalizations for conditions that can theoretically be managed outside an acute care hospital are preventable. Second, given fiscal constraints and the dearth of health care professionals trained in geriatrics and long-term care, not all nursing homes have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population.[1]

Inother words, the patient may be a stable transport to the hospital for a stay of a couple of days, but if the nursing home is not prepared to provide the necessary care, the patient could be unstable by the time an ambulance is called.

Unstable means that we will want to see a valid prehospital DNR (Do Not Resuscitate) order in Pennsylvania. Anything that is not a prehospital DNR and we are supposed to call medical command to receive permission to obey the patient’s wishes clearly documented on a valid legal document. Of course, this is presuming that the nursing home is able to provide any documentation at all.

A note, from the nursing home doctor on a prescription pad pretending to be a DNR order, should result in malpractice charges against the doctor. Not that I have any opinion on the matter, but we should expect more responsible behavior from Dr. Conrad Murray.

You’ve never seen a prescription written in crayon? OK, I haven’t either, but a DNR on a prescription pad is no less valid in crayon than in ink, or even in invisible ink. This is a non-DNR. What does the patient not want done? Who authorized this? Based on what consultation with the patient or family or court appointed representative? The incoherent rambling of dementia are no less valid.

Interventions designed to reduce preventable hospitalizations should therefore be directed at facilities that have the infrastructure, leadership commitment, and culture of quality and safety necessary to undertake more acute care.[1]

I have been impressed lately by some of the nursing home nurses. In different facilities, I have been told, The patient needs IV antibiotics. We can do that here. I don’t know why the doctor is sending the patient to the hospital for something we can provide here.

Maybe the nurses are getting a bit rogue and are not feeling that they are providing good care to their patients by just transferring a patient to the hospital every time the patient has a fever that lasts more than a few hours.

If you were the patient, would you prefer to be placed in an ambulance, on a thin mattress, bounced along just over the rear axle in this ambulance truck, to go to the ED. At the ED, the doctor does not know you, generally does not have all of the documentation he would want (DNR, living will, . . . ) to understand how aggressive to be in treatment. Then you may be admitted for a few days to build up strength for the return ambulance ride.

In many areas of the United States, realistic concerns about legal liability, as well as satisfaction on the part of nursing home residents and their families, affect hospitalization patterns. Thus, tort reform that limits liability for poor outcomes unrelated to the quality of care, and education of residents and families about realistic goals for care and advance care planning that considers the risks as well as benefits of hospitalization, can be key to reducing preventable hospitalizations.[1]

Imagine having the patient, the family, the nursing home staff, and the doctor all communicating about what is best for the patient,

Footnotes:

[1] Reducing Unnecessary Hospitalizations of Nursing Home Residents
Joseph G. Ouslander, M.D., and Robert A. Berenson, M.D.
N Engl J Med 2011; 365:1165-1167September 29, 2011
Free Full Text from NEJM

Joseph G. Ouslander, M.D., and Robert A. Berenson, M.D. (2011). Reducing Unnecessary Hospitalizations of Nursing Home Residents N Engl J Med , 365 (September 29, 2011), 1165-1167

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Representative Ruth McClendon Trying to Eliminate Patient Rights in Texas

But that answer wasn’t enough for Terry Read. He wanted to do more. And for the last two years he’s been working with State Representative Ruth McClendon to keep this from happening to anyone else.[1]

And what is that horrible thing that happened to Terry Read?

His father died. I can relate to that. My father died.

Terry Reid’s father, Samuel, had a living will. Apparently, Samuel Read’s living will stated that he did not want CPR.

My father also did not want CPR.

When my father collapsed, we honored his wishes.

When Samuel Read collapsed, Terry Read wanted him to stay alive, even though Samuel Read appears to have clearly expressed his wishes in writing. We want our parents to stay alive, but that does not give us the right to force medical treatment on them. Especially not when they have documented their wishes in front of witnesses who have determined that they have the capacity and the information to make this decision.

We are not gods. We cannot keep people alive forever. If we try to keep people alive forever, it is called torture.

Most of the relevant information is not included in the story. Because of HIPAA? No. Terry Read should have the authority to release any information he wants.

Most likely, the problem with the information is that Terry Read is not releasing it, because it does not support his story. He claims that the living will was violated, but where is the violation?

Let’s start with the errors in the story.

The Read family spoke with News 4 WOAI Trouble Shooter Mireya Villarreal and says EMS crews didn’t read the will correctly and made a big mistake.[1]

No.

That is not true.

If you disagree, provide some evidence that anything SAFD EMS (San Antonio Fire Department Emergency Medical Services) did was contrary to the wishes of Samuel Read.

Chief Grenato says paramedics on scene reviewed Sam Read’s living will with a medical expert over the phone; then decided to stop treatment. The state has reviewed this case and cleared the department of any wrong doing.[1]

The name of the Chief is Chief Granato, not Grenato.

I spoke with Melissa Sparks, Spokesperson for SAFD (San Antonio Fire Department). She confirmed the spelling of Chief Granato’s name. She also provided some other information that was not in the story.

then decided to stop treatment.

The paramedic did not decide to stop treatment. One of the medical directors for SAFD was contacted by phone. The relevant parts of the living will were read to the medical director. What is relevant is decided by the medical director, not the paramedic.

The medical director decided that stopping CPR was what the patient wanted and had clearly expressed in his living will.

 

This is the ethical thing to do.

 

To continue to treat a patient – against the wishes of the patient – is abuse.

 

It is not the job of EMS to abuse patients.

 

My condolences go out to Terry Read and the rest of his family, but Terry Read’s grief does not authorize him to deprive patients of their right to make decisions for themselves. Not even his father.

The state has reviewed this case and cleared the department of any wrong doing.

That is the Texas Department of State Health Services. In other words, there was no big mistake.

If anything, SAFD EMS deserves commendation. Could they have handled this more gently? Maybe. Maybe not. This is 2 1/2 years later, but Terry Read is still not responding to reason. Imagine how much less reasonable Terry Read was when he was faced with his father’s death?

Dealing with a cardiac arrest, regardless of whether we continue treating the patient, is a time of great stress for the family.

After pronouncement can be a great time for EMS to call a trusted neighbor, a pastor/rabbi/imam/priest, other family members, or whomever the family feel most comfortable with at the time of the death of a loved one.

What about State Representative Ruth McClendon?

She appears to be clueless about the EMS regulations and assumes that those of us in EMS are just as clueless.

“EMS personnel do not have the responsibility or the training or the knowledge to interpret legal documents,” Representative McClendon told us.[1]

We cannot understand the patient’s wishes, but we can perform miracles and bring terminally ill people back to full health?

Of course, Representative McClendon is completely misrepresenting what happened. EMS did not interpret the living will, the medical director did. Living wills are written for doctors, and other medical personnel, to interpret. Living wills are about the kind of care a patient wants. Living wills are not about arcane legal minutia.

“Emergency responders, paramedics, are not in the business of interpreting living wills. They’re in the business of doing what they’re trained to do, which is to administer emergency medical treatment,” Terry Read explained.[1]

They contacted medical command for permission to stop CPR and only stopped CPR after receiving orders from medical command.

Why is that so hard for Terry Read and Representative McClendon to understand?

She (Representative McClendon) sponsored House Bill 577, which was passed during this legislative session. It makes it very clear, a first responders’ first priority is to treat a patient.[1]

The only change is the strong suggestion that we should refuse to respect the wishes of the patient, just to put on a show for families who do not respect the wishes of their family members.

SAFD EMS did treat Samuel Read first, then the paramedic contacted medical command and then followed medical command orders.

C.S.H.B. 577 contains a provision not included in the original requiring the emergency medical services system’s medical director or online physician, if a person’s personal physician is not present or does not assume responsibility for the care of the person while the person is receiving emergency prehospital care, to be responsible for directing the emergency medical services personnel who are providing emergency prehospital care to the person and authorizing the director or online physician, under such circumstances, to order the termination of cardiopulmonary resuscitation only under specified conditions.[2]

That is exactly what happened. Everything SAFD EMS did for Samuel Read was in compliance with the new law.

This law is a feel good law, but it may persuade people to abuse patients, rather than treat patients with respect.

This should be titled the Encouraging Abuse of Terminal Patients Bill.

Representative McClendon should be ashamed of her actions. So should everyone else who voted for this.

Patient care is about the patient.

The patient is Samuel Read.

Samuel Read did not want to be resuscitated.

Also read the writings of Medic Madness and The Social Medic on this –

Since when is it not our responsibility?

Are We Encouraging The Abuse Of Terminally Ill Patients And Their Families?

Footnotes:

[1] EMS workers stop medical treatment after reading will in the field
Mireya Villarreal
July 27, 2011
WOAI
Article

[2] House Committee Report Analysis of Bill
HB 577
Authored by Representative McClendon
House Analysis of Bill and a lot of other documents related to this bill at the Texas Legislature information page

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Advance Directives

Some more writing on the topic of advance directives.

As with Dr. Boris Veysman,[1] I have begun resuscitation in the absence of awareness of a DNR.

Unlike Dr. Veysman, when I have learned after transport to the ED, I have responded with an apology and an explanation that I did not know and certainly would not have abused their family member if I had known.

Walt Trachim writes about one such situation in DNR’s: Yes or No?.

Dr. Veysman seems to have had the perverse response of – But look at what a great result I produced by abusing your loved one!

In Dr. Veysman’s defense, I do feel that it is important to point out that Dr. Veysman does advocate for very aggressive pain management.[2] I do not believe that he is at all malicious.

I think that one of the big problems with medicine is that so much harm can be done without any malice.

The most important thing mentioned in DNR’s: Yes or No? – after some undeservedly kind words (prolific could go either way), and a few cases relevant to the topic, is the main point.

And now – because of the facts and opinions that I’ve read – I have to think about it. How can I not?

Exactly.

One way of addressing this unintentional harm is with the POLST. Dr. Eric Widera writes about this in POLST: Standardizing End-of-Life Orders rather than Patient Communication.

Twelve states have adopted the POLST paradigm into law (CA, HI, ID, MD, NY, NC, OR, TN, UT, WA, WV), and many more are developing programs. My state (California) has signed the POLST into law, although implementation in San Francisco is spotty at best.

The Coalition for Quality at the End of Life (CQEL) is a link to more information on end of life issues.

National Health Care Decisions Day 2010 is at Pallimed.

From Happy National Health Care Decisions Day! at Asystole is the Most stable Rhythm, I picked up a link to a post by Dr. Grumpy. There are a lot of comments. Checkout time.

Finally, the most recent post, The Arrogance of Hope is the dissection of Dr. Veysman’s article at Movin’ Meat.

Footnotes:

^ 1 ‘Shock me, tube me, line me’.
Veysman B.
Health Aff (Millwood). 2010 Feb;29(2):324-6. No abstract available.
PMID: 20348077 [PubMed – in process]

Free Full Text from Health Affairs         Free PDF from Health Affairs

^ 2 Truth hurts.
Veysman BD.
Acad Emerg Med. 2009 Apr;16(4):367-8. Epub 2009 Mar 6. No abstract available.
PMID: 19298618 [PubMed – indexed for MEDLINE]

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Shock Me, Tube Me, Line Me

The emergency department (ED) is always noisy, but sudden screams from a staffer still get attention. The triage nurse is yelling, “…Not breathing, had vitals at triage, and just croaked,” as she runs toward us pushing a wheelchair. In it, a pale, thin woman is slumped over and looking gray. I’m the ED attending physician in charge. Amid the usual strokes, heart attacks, and bleeding ulcers, my day just became interesting.[1]

Amid the usual strokes, heart attacks, and bleeding ulcers, my day just became interesting.

This line just makes me want to cry.

First, I want to point out a bit about Dr. Veysman. He has written one of my favorite journal articles on pain management.[2] Here, he does demonstrate an appreciation for the possible pain the patient may experience throughout the resuscitation. However, resuscitation decisions are about more than pain.

Resuscitation – all of medical care – is about autonomy.

If the patient has the capacity to make informed decisions and is provided with appropriate information to make an informed decision, we need to respect that decision.

“Anyone know of a DNR on her?” I ask. If there’s a Do Not Resuscitate order, we won’t prevent her impending death, which means no chest compressions or electric shock for a dangerous heart rhythm. If there’s also a DNI (Do Not Intubate) order, we won’t insert a tube to help her breathe.

Blank stares all around. “Her daughter dropped her off with a chief complaint of weakness and went to park the car. I think she has cancer and is on chemo,” the triage nurse says. Without concrete proof of a DNR or DNI, there’s no hesitation. We resuscitate; we intubate. Click, klang, the laryngoscope snaps open and the patient has a tube down her throat within seconds. On the monitor, she is “flatlining”—no heartbeat—and she has no pulse.[1]

Concrete proof?

The decision to resuscitate should probably be prejudiced in favor of resuscitation, but have we gone too far in our attempts to do the impossible?

We are attempting to prevent death. We can only delay death. In some cases, we only prolong death.

We are also attempting to prevent being sued by someone for failure to treat a patient who could potentially be resuscitated. Is making the patients endure treatments they would refuse, if presented with accurate information for informed consent, acceptable if we do it to protect ourselves from liability?

Why is it considered ethical to subject patients to treatments just to protect us from the possibility that they might sue if there is a bad outcome? We do need to reform the way malpractice is handled, rather than force unwanted treatments on patients because of What if . . . ?

What if . . . ?

What if we treat patients with respect?

What if we present patients with the information they need to make informed decisions?

What if we allow patients to make those decisions, themselves?

We are there to help patients to live the lives they want to live. We are not there to impose our beliefs on them.

While I know that legally the lack of a DNR significantly ties our hands, I would expect most doctors to send someone running to find the daughter, who went to park her car.

I have worked in EMS in three states. Each state has made it clear. If I feel uncomfortable honoring a DNR, I am not required to respect the wishes of the patient. I can go above and beyond, but only in resuscitation, certainly not in pain management, or sedation. Ethical behavior in those cases would be very, very wrong.

I have known doctors willing to violate a DNR, but very few. I have known a lot more people in EMS who feel comfortable violating a DNR. Unfortunately, in Pennsylvania, the patient needs to have an original Prehospital DNR or we need to call medical command to get permission to honor a regular DNR or to honor any other kind of advance directive. There seem to be a lot of EMS people who will not make that call.

It appears that very few doctors in Pennsylvania are aware of this requirement for a Prehospital DNR, although it is stressed to EMS. If the patient does not have this bracelet or necklace or original document, we must start CPR.

The current approach is not the only possible approach, it is just the only one that people seem willing to discuss. Stefan Timmermans presents the other end of the spectrum. We do not need to go that far, but we are still too close to the other extreme. We do need to be more flexible in our approach to the inevitable.

If no relatives or friends are present, if I have no personal ties with the person dying, if I do not know the person’s wishes, and survival is not a near certainty, I would follow the advice I once heard a paramedic give a colleague: “If I were to collapse suddenly, close the door and check back in twenty-five minutes.” I would chose not to start CPR, and I would make the decision in good conscience. I would decline to subject a dead person to an invasive and traumatic intervention.[3]

We have patients who have valid DNRs, but they are not Prehospital DNRs. In Pennsylvania, the EMS law has rewritten the rules for patients who had every reason to expect that they were signing a valid document that would prevent unwanted attempts at resuscitation. Unfortunately, the patients have not read the fine print – fine print that is not on their DNR – invisible fine print clearly stating that they are using the wrong DNR for a patient outside of a hospital.

If I were diagnosed with a terminal condition and asked my doctor for a DNR, would my doctor know that there is only one acceptable form of DNR outside of a hospital in Pennsylvania?

If I were to visit someone in Pennsylvania from another state, would anyone realize that this would invalidate my out of state DNR, while I was in Pennsylvania?

If I obtain any other form of valid advance directive, will it been explained to me, that the EMS rules in Pennsylvania (and possibly most other states) make these valid legal documents essentially worthless outside of a hospital. Will I be told that I am wasting my time by jumping through hoops to document my wishes for treatment in advance of that need, when I still have the capacity to make those decisions?

Why does the person writing the EMS rules have the authority to tell those of us in EMS to ignore valid legal documents?

The answer from EMS management is that these documents are not valid, since they are not the document approved by the EMS department.

Why does the person writing the EMS rules get to decide what is a valid document?

Why is a written, witnessed, signed statement of an informed decision not valid only because it does not meet the standards of the people who oversee EMS?

Fear.

We refuse to make difficult decisions, because we are afraid of the possibility that this patient, this time might be one of the few who might be capable of being resuscitated, if only briefly and painfully. A jury is expected to be unreasonable and to claim, They didn’t even try.

But what really happens when EMS is called?

With any advance directive that is not a Prehospital DNR, we are expected to start CPR before calling medical command for permission to honor the patient’s wishes. In other words, we are expected to force unwanted treatment on the patient because they do not have the right paper.

Someone calls 911 because the police have stopped using non-emergency numbers, as many police departments have done. Marauding vandals beheading your neighbors? Call 911. Barking dog? Call 911. Where can I get my car inspected? Call 911.

The family member is only calling to notify someone of a death, but it is an emotional time and they may feel they need to notify the police. 911 is the only number to reach the police. An ambulance is dispatched because there is a dead body. Never mind that this is a patient, who was receiving hospice care, and that there is nothing unexpected about this death. EMS arrives.

Maybe there is a DNR, but nobody can remember where it is. CPR must be begun, while the family looks for the paperwork. Thought you were stressed looking for your keys, when you were running late? Wimp.

Maybe there is a DNR, but it is only a copy, and EMS can only honor the original document. CPR must be begun. Maybe EMS calls medical command for permission to stop CPR. Maybe medical command grants permission.

Maybe there is a DNR, but it is not a Prehospital DNR. CPR must be begun, while the family blames themselves for this mistake. Perhaps EMS blames them as well, after all, that is what we have been taught during our DNR classes. It is the family’s fault. Maybe EMS calls medical command for permission to stop CPR. Maybe medical command grants permission.

Maybe there is an advance directive. CPR must be begun. Maybe EMS calls medical command for permission to stop CPR. Maybe medical command grants permission.

Maybe the patient is in a nursing home. The paperwork is not a Prehospital DNR. Since this is a patient in a nursing home, the paperwork is usually a note, scribbled in the margin, stating that the patient has a DNR. That kind of documentation is not even valid in the emergency department. Maybe there is a copy of the DNR paperwork. Maybe it is legible. Maybe EMS calls medical command for permission to stop CPR. Maybe medical command grants permission. Maybe the check is in the mail.

Most of the time, when I pick a patient up from a nursing home, when I ask about DNR status, they will tell me the DNR status, but they will not have the original paperwork. Sometimes there will be contradictory notes on the paperwork. On one page it states, Full Code, while on the next page it states, DNR.

It is as if we do not expect patients to have life threatening illnesses in nursing homes. Nursing home patients never go to the emergency department.

Then there is the problem of the escape clause. If an EMS provider does not feel ethically comfortable honoring the patient’s DNR, even if it is the Gold Standard Prehospital DNR personally signed by the state medical director, the medic’s medical director, and the medic’s mother, any EMS provider may decide that they just don’t want to respect the patient’s wishes. Dude, I haven’t had a tube in a while – Game on!

There is no provision for an EMS provider to acknowledge the obviously unethical rules and refuse to perform CPR on a patient with an advance directive, with the family all in agreement that their family member does not want CPR, and with a patient who has clearly wasted away over a period of weeks. A patient who would not have anything to look forward to, except having to die again if resuscitation produces a heart beat.

CPR was never intended to treat terminal illness.

I was called for a 51 year old patient with respiratory distress. He has a terminal respiratory condition. He has a DNR. He only needed treatment for an exacerbation of his underlying condition, so I did not have to deal with his DNR, but he did have a DNR. After the call, the two EMTs on the ambulance told me they would not honor the patient’s DNR, because he is too young. In EMS you can get away with that, because that is considered ethical to refuse to honor a DNR.

To sum up all of that, we need to change the rules, so that the rules serve the patients, not the other way around. We need to do this in a way that is ethical, and the current system definitely does not.

To me, resuscitating a cancer patient with a DNR puts me in the same league as those who provide medical care during torture. Keeping the person alive only so that they may experience the most pain possible. Dr. Veysman’s statement about his view of the same situation, “Amid the usual strokes, heart attacks, and bleeding ulcers, my day just became interesting.” That just breaks my heart.

I have had to call for medical command permission to stop CPR, not to withhold CPR, since we are supposed to be performing CPR while calling for permission. In the case of an advance directive, every time I have requested permission, medical command has agreed.

I cannot state that I withheld CPR while calling medical command, because that would be wrong. Of course I treated the family and the patient as if they are criminals having this forced on them for some valid reason. Of course I did. After all, that is what the state tells me is the only ethical thing to do.

Did I mention that, on one of these occasions, I waited for over eight minutes for the person who answered the phone to track down the medical command physician for permission to honor an advance directive?

Over eight minutes.

Only a medical command physician is supposed to answer the medical command phone.

Over eight minutes.

If I were giving epinephrine every 3 to 5 minutes and amiodarone in between, I would have maxed out on amiodarone before eight minutes. There is no maximum for epinephrine.

Over eight minutes.

Finally, the person on the other end of the line had to admit, I do not know where the medical command physician is. Maybe you could call another hospital.

Over eight minutes.

Then, I called another hospital. The medical command doctor picked up the phone. Permission granted to stop CPR. That is stop CPR, because I was certainly performing CPR the whole time, rather than attending to the needs of the family. To withhold CPR from someone who has clearly stated that it is not wanted would be very, very wrong.

I do not know what I would have done if I had been ordered to perform CPR, intubate, give drugs, et cetera. If I refused, would that prevent me from obtaining a job in a respectable line of work, such as prostitution? Fortunately, I have not had to find out. I am grateful every time I sit down.

Dr. Veysman does seem to have an interest in pain management and in avoiding suffering, but he seems to be suggesting that anyone with less of a love of their life, than what he thinks is appropriate, is making a mistake and needs to be preached to. I completely disagree with that approach.

If a person has made their own informed decision about what treatment they want, we should not be preaching at them to change their minds. I know too many people who will ignore the wishes of a patient with respiratory distress, after the patient makes it clear that intubation is not wanted, because the patient must be hypoxic and therefore the patient’s wish is not an informed decision. These same people will keep asking a patient with a DNR,Do you want us to save you? or Do you want us to help you breathe? Any positive indication at any point must be an informed decision by the patient to revoke their DNR, even though the patient is no less hypoxic than the patient who disagrees with them.

When guided by belief, too many of us only look for evidence that supports our belief.

Respecting the informed decisions of patients is an important part of medicine.

Back to the article.

“Unless the asystole is from too much potassium,” I reply. That would explain it. “Get two amps of bicarbonate. Take over compressions,” I say to the intern. “Central line kit, please.” The intern looks disappointed. He was hoping to do the line. I whisper, “Next time.” His training is important, but I’ll teach him more by saving the patient. Learning is slow, and slow is often OK—and sometimes better—because slow is careful. But this patient will die from slow. It’s a good lesson for him.[1]

But the first treatment for hyperkalemia ought to be the one that works fastest. Calcium.[4] Preferably calcium chloride, rather than calcium gluconate. Sodium bicarbonate only comes later. Perhaps the bicarb addressed something else.

Technicians attach the pads to the patient’s right shoulder and left ribs. “Guys, I know that’s the way the drawing’s shown on the pads,” I say, “but I want them on front and back. You’ll get better capture.” By this I mean that the electrical stimulus will be transferred more effectively and will better induce the heart to contract.[1]

On this, I completely agree. Anterior/posterior pad placement minimizes the amount of tissue the electricity needs to penetrate. This means that less energy is needed to obtain capture. This makes pacing more comfortable for the patient.

The pacer is working. Now there is a strong pulse, great blood pressure of 150/80, and her pupils are beginning to constrict, suggesting decent blood flow to the brain. I order a calcium infusion, another ampule of bicarb. The vitals stabilize. She maintains a normal rhythm without a pacer.

“Electricity works,” we like to say, and I’m grateful that the pacer did its job and is no longer necessary.[1]

A lot of things work, that does not mean that one causes the other. Was the electricity what worked this time? While the pacer can be a dramatic intervention, is there a reason to conclude that the patient improved because of the pacer? Maybe. Maybe not. We cannot tell from the article.

I introduce myself, and before I can go further, a man interrupts and hands me papers. “She has DNR and DNI orders,” he says.[1]

I carefully explain that everything happened fast. We weren’t aware of the DNR and the DNI.[1]

These are legitimate excuses, but they are only excuses. How hard did they try to find out if there was a DNR? When presented with a patient reported to have cancer, I am looking very aggressively for some way of determining what the patient wants done. Is there a DNR? Is there some other documentation of the patient’s wishes? What has the patient expressed to family members? What kind of cancer? What kind of prognosis? What treatments is the patient receiving? How has the patient been responding to the treatments? Et cetera.

For another perspective on the approach of Dr. Veysman, I decided to consult the writings of someone who might be able to tell me if the article reflects some hubris on the part of Dr. Veysman. Chess With God by Dr. Veysman.[5]

I suspect that Dr. Veysman is making a reference to The Seventh Seal,[6] where a man plays chess with death during the Black Plague. Yet, Dr. Veysman did not fool death. I would have used a different metaphor.

Without concrete proof of a DNR or DNI, there’s no hesitation.[1]

I think we need more hesitation, more discretion, and certainly more respect for patients.

Also covered in –

An ER Physician’s Take on DNR Orders
by Dr. Eric Widera

HEALTH CARE: This Is Why We Need Palliative Care
Author(s):Joanne Kenen
Published: March 3, 2010

For This Doctor, ‘DNR’ Means Do Not Resign
by Boris Veysman
NPR
morning edition

Footnotes:

[1] ‘Shock me, tube me, line me’.
Veysman B.
Health Aff (Millwood). 2010 Feb;29(2):324-6. No abstract available.
PMID: 20348077 [PubMed – in process]

Free Full Text from Health Affairs         Free PDF from Health Affairs

[2] Truth hurts.
Veysman BD.
Acad Emerg Med. 2009 Apr;16(4):367-8. Epub 2009 Mar 6. No abstract available.
PMID: 19298618 [PubMed – indexed for MEDLINE]

[3] Sudden death and the myth of CPR
By Stefan Timmermans
Link at OpenLibrary.org

[4] The Wrong Juice
Movin’ Meat
by Shadowfax
Article

[5] Chess with god.
Veysman BD.
Ann Emerg Med. 2010 Jan;55(1):123-4. No abstract available.
PMID: 20116017 [PubMed – indexed for MEDLINE]

Free Full Text from Annals of Emergency Medicine
Free PDF from Annals of Emergency Medicine

[6] The Seventh Seal
IMDB link

.