Wednesday, November 29, 2017

More Spoiler Alerts now that I have Watched the First Season of Stranger Things

So in the last episode of Season One of Stranger Things, there is a scene in which the Chief of Police has a flashback to the death of his daughter.  She is clearly dying of cancer, and the medical team is running a resuscitation code to try to "bring her back".

Why?  Why on earth would any physician run a code on someone with a terminal cancer?

One could argue that it's just television, but my understanding of the US medical system is that it isn't uncommon for people with terminal cancers to have CPR performed on them, to be intubated, and to be admitted to the ICU.  Which isn't at all the way things are practiced at the institutions where I trained.  Generally, when someone has a clearly terminal illness, the medical team will try to talk with the patient and his/her family to get them to choose a do not resuscitate order.  Sometimes the ICU will even refuse to take terminally ill patients.

Which to me seems to be the ethically right decision.  CPR is a horribly violent thing to put someone through, and few patients survive it to go on to have a meaningful quality of life.  For myself personally, I would only want resuscitation attempted if there was a reasonable chance of me recovering and surviving long-term.  If I had a terminal illness* and my heart stopped, I would want to be allowed to die without intervention.

And I don't think this is just my personal preference.  In my experience, most patients choose a DNR order when they are properly informed about what an attempted resuscitation entails and how low the survival rates are.  A refusal to accept a DNR is generally a result of poor communication from the medical team.

Thoughts?  For people in the medical profession, what have you seen in your institution(s)?

*God forbid, knock on wood, throw salt over my shoulder, etc.

13 comments:

  1. I've worked in an American ER and I've seen terminal patients put through CPR (flogged, is what I call it)at the insistence of the family. The patient starts to actively die at home, the family freaks out and calls 911 and then when the patient arrives at the ER, the family wants everything done, usually because "they aren't ready to say goodbye yet." It's incredibly frustrating and sad. I think that greater access to hospice care and better physician-patient-family communication is the key to reducing this issue.

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  2. I watched my cousin with terminal cancer receive CPR. There was no hope, but it was at the request of my aunt and uncle. Watching the CPR take place did provide closure to them. That way, they could know that everything possible was done, and it gave them peace of mind that it was indeed time for her to go.
    They were offered hospice and palliative care, but no one in the family, including my cousin, was willing to give up hope of a cure.

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  3. This just makes me eternally grateful for my parents, who have both made it clear to me (verbally and with written documentation) that if they're ill and the shit hits the fan, I am to "let them go". I think knowing someone's wishes on this beforehand is so important.

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  4. My mom (85 years old) had medically assistance in dying (MAiD) this summer.

    https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/end-of-life-care/medical-assistance-in-dying

    She did not have a terminal diagnosis but did have "intolerable suffering". Her death was peaceful and "good" and I greatly respect her choice and am glad she had the option.

    And yet, it's still very difficult. There's no "letting them go" when it's their time. She chose her time. One minute you're talking and laughing and then a few minutes later, she's gone.

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    1. I am so sorry that your mum died.

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    2. But I'm glad she go to go peacefully and well. I was able to help both of my parents die calmly at home. Hospice helped a lot.

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  5. I totally agree with you. And by the way, I think I love you/

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  6. I worked on a thoracic surgery ward and one day a terminal patient who was "brought back" at his home hospital was transferred in. He suffered for a couple of months before succumbing to his terminal cancer. I never want to see anyone suffer like that again. Apparently his family just couldn't let go.

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    1. P.S. That was several decades ago and I think things have gotten better now.

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  7. As a registered nurse in the US, I used to see this kind of thing, but not for years. We have come a long way, but have a long way to go. Some MDs just won’t or can’t talk with their patients and family members very well about anything. Some families are just dysfunctional, or misinformed, and some patients are just frightened and very confused. Most of the time, someone (ethics committee, etc.) at the hospital will make sure this doesn’t happen, but why take the chance?? EVERYONE of any age needs advance directives, which means a Living Will and, ideally, a Do Not Resuscitate form. This would prevent the horrible meaningless resuscitations that lead to “vegetables” suffering in nursing homes for years. Even if we are young and healthy, things happen unexpectedly. I know my husband would panic and make bad decisions for me, so everything is in writing and I have 2 siblings who would be able to make sure my wishes are followed. To get the FREE paperwork, check with a local hospital or hospice, or maybe your state’s medical society. It’s probably available online as well. And talk to your doctor so she knows what you want…
    TV shows and movies are AWFUL about showing dumb stuff that would never happen. I haven’t seen that show you mentioned, but there have been a few recently that were incredibly stupid, such as
    The Good Doctor” (doing surgery outside almost every week, or in helicopters; one small group of doctors runs an entire university medical center), or The Red Band Society. Don’t bother to watch, they’re terrible. I did like Scrubs and St. Elsewhere. They were comedies and pretty far-fetched sometimes, but they cam almost close to what goes on.
    Thanks for bringing this up so people can be aware and start talking about it.
    Jenny

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  8. Is it awful that I came to my own conclusions about CPR and DNR after working some years at an animal hospital and as a pet owner? People struggle so much to let go, including me, and I think it has a lot to do with not accepting death in our society. After many years of losing relatives, and beloved pets, I realized that it's not worth going all lengths to save someone when they don't have a good prognosis before crashing.

    Knowing that it's incredibly hard to make those decisions in the moment, PiC and I are having these discussions now so that we know and have it in writing in case something terrible happens.

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    1. Not awful at all! I think it's good to have an understanding of what the dying process entails, wherever that comes from. My understanding of death/CPR/DNR definitely evolved over the course of my training, and I've gotten much more accepting of death with time.

      I agree completely that we don't accept death in our society. It isn't something that is discussed openly, and the medical culture makes it seem like it's something that can be avoided with the right care and the development of the right drugs. Which it obviously can't! When I was in Chicago a few years ago, I went to an exhibit on Dia de los Muertos at the National Museum of Mexican Art, and I loved the idea of death being something that was honoured and in some ways even celebrated. It seemed like a much healthier attitude than the Canadian/American one.

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  9. I was not able to convince my father to actually write an advanced directive during his terminal illness since he was convinced that he wasn't dying, but I was able to take notes on his wishes. I shared these with the hospital system and our family. They weren't legally binding, but it was a good help. There was nothing anyone could do to convince him he was dying though. It was hard to see.

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