Advance directives -- 楊署長請大家一入院就想好DNR及器官捐贈與否，is it good? -> not in USA
http://tinyurl.com/2wx7j8t
一個美國critical care physician 的感想，基本上和我們差不多
預立病危處理方式無法解決問題…
Death & Dying in the ICU
David Kaufman, MD, Critical Care/Intensive Care, 11:05AM Sep 9, 2010
I wish it were possible not to be so preoccupied with this theme, but it seems impossible to ignore the reality of the ICU (at least in my part of the USA). I just finished 2 weeks of ICU service, and it is striking how many patients come to the ICU to die, when, with a little careful examination, their dying process would be recognizable to their doctors, who could make it recognizable to the patients' loved ones. I feel like I lost count of the very elderly (85-plus years), emaciated, demented souls who came to us from nursing homes with sepsis, intubated in the Emergency Department, with only a small chance of getting off the ventilator.
We often think that Advance Directives would be the answer, but at least in my state, Advance Directives only cover a limited range of situations. I am reminded of an excellent article from the Annals of Internal Medicine some years ago that detailed all the places where Advance Directives can, and do, fail to help patients with end-of-life decision making. It is made more difficult by trying to understand when and how many long-term diseases such as CHF, COPD and dementia become "terminal." It would be great to have more studies like the recent one from the New England Journal of Medicine that outlined the natural history of advanced dementia.
Even so, I fear that we are often put in a difficult position like the one in which I found myself last week. We admitted an elderly man with advanced dementia and ischemic cardiomyopathy from a nursing home. On a previous hospital admission, he had been transitioned to hospice care, but his wife and daughter had reversed that decision, along with the "DNR-DNI" order that went with it.
He had severe diarrhea that resulted in volume depletion, hypernatremia and hypokalemia (K=2.9). He was admitted to the ward and prescribed 40 of potassium through his gastrostomy tube. On the first night, he had pulseless V-tach and ended up on a ventilator with norepinephrine infusing. His wife specifically requested that he receive all available therapy until September 1, because she had bad memories of a death that occurred in August. Our ICU staff kept his vitals signs going for several days as his urine output trailed off, his creatinine rose, severe ileus set in and his low level of responsiveness gradually slipped into deep coma. His central line was accidentally pulled out and his wife insisted that a new one be placed for continued norepinephrine infusion. On September first, as she planned, she requested that vasopressors and the ventilator be withdrawn.
It is difficult to imagine how written Advance Directives would help in a situation like this, since many caregivers and hospital administrators would be leery of withdrawing life support against a family's wishes, even in the presence of a patient's clear statements. Since Ethics Committees and dispute resolution often take many days or weeks to arrive at a decision, these processes would probably not work in the time frame specified here.
Instead, the ICU team felt demeaned and spiritually defeated when providing potentially painful intensive care to a dying patient while satisfying a relative's seemingly arbitrary deadline. It made us feel like waiters at a restaurant, where families can order the therapies they desire, regardless of the risk and benefit to the patient. And of course, for the families, it's free (or at least the tab is picked up by Medicare.)
http://www.annals.org/content/147/1/51.abstract
https://docs.google.com/fileview?id=0B278nGJMQBk7OWNjZTIyYWYtZGU1Mi00Mzg4LThhNDEtNjNlODNjMGJhM2Y1&hl=zh_TW
Annals of internal medicine 的文章，Controlling Death: The False Promise of Advance Directives => 死亡是不可控制的，羊頭…
一個美國critical care physician 的感想，基本上和我們差不多
預立病危處理方式無法解決問題…
Death & Dying in the ICU
David Kaufman, MD, Critical Care/Intensive Care, 11:05AM Sep 9, 2010
I wish it were possible not to be so preoccupied with this theme, but it seems impossible to ignore the reality of the ICU (at least in my part of the USA). I just finished 2 weeks of ICU service, and it is striking how many patients come to the ICU to die, when, with a little careful examination, their dying process would be recognizable to their doctors, who could make it recognizable to the patients' loved ones. I feel like I lost count of the very elderly (85-plus years), emaciated, demented souls who came to us from nursing homes with sepsis, intubated in the Emergency Department, with only a small chance of getting off the ventilator.
We often think that Advance Directives would be the answer, but at least in my state, Advance Directives only cover a limited range of situations. I am reminded of an excellent article from the Annals of Internal Medicine some years ago that detailed all the places where Advance Directives can, and do, fail to help patients with end-of-life decision making. It is made more difficult by trying to understand when and how many long-term diseases such as CHF, COPD and dementia become "terminal." It would be great to have more studies like the recent one from the New England Journal of Medicine that outlined the natural history of advanced dementia.
Even so, I fear that we are often put in a difficult position like the one in which I found myself last week. We admitted an elderly man with advanced dementia and ischemic cardiomyopathy from a nursing home. On a previous hospital admission, he had been transitioned to hospice care, but his wife and daughter had reversed that decision, along with the "DNR-DNI" order that went with it.
He had severe diarrhea that resulted in volume depletion, hypernatremia and hypokalemia (K=2.9). He was admitted to the ward and prescribed 40 of potassium through his gastrostomy tube. On the first night, he had pulseless V-tach and ended up on a ventilator with norepinephrine infusing. His wife specifically requested that he receive all available therapy until September 1, because she had bad memories of a death that occurred in August. Our ICU staff kept his vitals signs going for several days as his urine output trailed off, his creatinine rose, severe ileus set in and his low level of responsiveness gradually slipped into deep coma. His central line was accidentally pulled out and his wife insisted that a new one be placed for continued norepinephrine infusion. On September first, as she planned, she requested that vasopressors and the ventilator be withdrawn.
It is difficult to imagine how written Advance Directives would help in a situation like this, since many caregivers and hospital administrators would be leery of withdrawing life support against a family's wishes, even in the presence of a patient's clear statements. Since Ethics Committees and dispute resolution often take many days or weeks to arrive at a decision, these processes would probably not work in the time frame specified here.
Instead, the ICU team felt demeaned and spiritually defeated when providing potentially painful intensive care to a dying patient while satisfying a relative's seemingly arbitrary deadline. It made us feel like waiters at a restaurant, where families can order the therapies they desire, regardless of the risk and benefit to the patient. And of course, for the families, it's free (or at least the tab is picked up by Medicare.)
http://www.annals.org/content/147/1/51.abstract
https://docs.google.com/fileview?id=0B278nGJMQBk7OWNjZTIyYWYtZGU1Mi00Mzg4LThhNDEtNjNlODNjMGJhM2Y1&hl=zh_TW
Annals of internal medicine 的文章，Controlling Death: The False Promise of Advance Directives => 死亡是不可控制的，羊頭…
留言
張貼留言