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

- Rogue Medic

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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