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Posted by Ishani Ganguli May 21, 2012 07:00 AM
In the standard patient interview, stuck somewhere between drug allergies and the review of symptoms, lies a question thatís a tad more existential: how do you want to die?
I wrote recently about patients and their families making this difficult choice in the Intensive Care Unit. Now Iím back on a regular medical service, where thereís a more comfortable distance between life and death and the question is often hypothetical: if your heart were to stop, would you want chest compressions in an attempt to bring you back to life (ie. CPR, or cardiopulmonary resuscitation)? But it doesnít make the conversation any easier.
Thereís debate about the right time and setting for the end-of-life discussion: Most favor having it with a primary care doctor or another long-term provider that a patient knows and trusts. Some argue that a patient isnít ready to have the conversation until a hospital stay throws his mortality into sharp relief. The reality is that itís our job as doctors to know the answer to this question every time a patient arrives on the hospital floor, and the task often falls to an intern working in the middle of the night. Unfortunately, trainees and even full-fledged doctors donít do a great job of having this discussion:
We ask out of the blue, instead of placing the questions in the context of a patientís broader goals for her life and death. The way we ask about, and document, the end-of-life decision (ďfull codeĒ versus ďdo not resuscitate (DNR)Ē) creates a false dichotomy between doing something and doing nothing and fails to capture either the shades of gray in end-of-life care or the value of doing ďnothing.Ē We donít present a realistic view of the violence of chest compressions, nor the probability of surviving past CPR (in the elderly and chronically ill, less than five percent. It doesnít help that in the movies and television, a common source of information on CPR, characters who go into cardiac arrest are usually brought back from the dead with a few thumps to the chest. We present a daunting list of end-of-life options (CPR? Breathing tube? Defibrillator?) with little guidance on navigating it - the medical version, maybe, of the menu at The Cheesecake Factory. In our quest for patient-centered care, we forget that itís still our job to frame choices and render them manageable.
I know I've made these mistakes at times. Iíve left a patientís room and worried that the decision I entered into the computer was ill-informed. But through personal trial and error, Iíve started to take a different approach to these code discussions. I try to be as honest as possible about what CPR looks like and what a patientís chances are for coming out of it alive (studies suggest this leads patients to choose less aggressive care). I use a term I learned in the ICU: ďallow for natural death,Ē which I think does a nice job of capturing the spirit of DNR. Some of my colleagues at MGH are using videos to make the conversation easier, and have found in pilot studies that terminally ill patients who watch the videos are more likely to opt out of CPR.
End of life discussions are fraught with emotion and personal biases (our patientsí, of course, but ours as well). As physicians, the best we can do is to speak frankly about the options and help our patients make the decisions that are best for them.
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