I suppose I should preface this one with a disclaimer. These views are my own and do not reflect the organization I work for. My views and perspective are shaped by what is probably over 20 years in the hospital setting. The includes being a hospital volunteer, an ER Clerk , Med School, Residency and I'm completing my 9th year as an attending, a hospitalist.
Since many of my patients look at me quizzically about what that means. It means I'm an internal medicine trained doctor practicing in the hospital setting taking care of acute admitted patients. So if someone has pneumonia, COPD , heart failure and they need to be in hospital, then I'm that rounding doctor.
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From admission, one of the first things explored as part of a patient's history and care approach is code status or advanced directives.
There are all kinds of ways to approach this and I've heard from mentors , family friends, why even ask? Shouldn't we do "everything?" Shouldn't the default be CPR?
I find this perspective .. paternalistic and not really one of shared decision making.
What do I mean? Shouldn't we extend life, preserve it , isn't that standard of care?
Well, I think like any intervention, there should be a dialogue. How will this intervention, like other interventions.. dialysis, chemotherapy, transplant should be discussed.
Will it help? What would be likely outcomes after? Is that in line with what that person wants to envisions their life to be like?
I also think it's important for doctors to share their concerns, opinions about appropriateness. Someone who is medically frail, malnourished with comorbidities will not have a positive outcome after CPR, if CPR is successful in restoring circulation. There's a feeling, a vibe when the doctors and nurses feel.. "we don't want to code that person, that would be ____ , it would be futile"
That should be shared with patients and families.
It's worth understanding the following:
Owing to early detection and advanced resuscitation, return of spontaneous circulation (ROSC) is achieved in 70–75% of IHCA cases3. However, the survival-to-discharge rate of IHCA ranges from 20 to 25%, which is considerably low4. This is because as patients with various medical complications are usually hospitalized, IHCA generally occurs in patients in a clinically deteriorated state. Therefore, failure of various organs, accompanied by neurological conditions and complications, must be considered in cases of IHCA5.
https://www.nature.com/articles/s41598-023-44312-2
So what does that mean. Despite our technique being better at achieving ROSC, surviving to discharge is low.
So let's get to a story. Recently I took care of a lady who had a complex hospital course. Prior to admission she had stable heart failure, advanced kidney disease and came in for a infection/podiatry issue. She was medically frail, geriatric age and while stable, chronically sick. Unfortunately her condition deteriorated to the point that she needed advanced cardiac medications that she could not tolerate and then to further complicate matters, she had progressive renal failure. While there are many elements to this case including trust/rapport/communication, one thing that is worth highlighting is that she remained "CPR" or full code even as her conditioned worsened.
Well, isn't that her choice?
We unfortunately given her condition, it became her choice as understood by her family, her surrogate decision makers.
I remember coming to bedside in the evening to meet her husband and explain my fears/concerns that her condition would worsen and lead to a cardiac arrest. It was my advice to consider DNR/hospice given her inability to tolerate advance cardiac medications and family's decisions to forego dialysis.
Ultimately, it took the patient going to the cardiac unit on multiple support medications and a series of conversations to finally make her comfortable, passing a few days later.
I wasn't the only one who wished/felt that we could have focused on the patient's comfort much earlier given the medical assessment that her condition was declining , but we worked closely with the family and palliative care to try to get them to that same space.
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This isn't the first case where I'm had a strong feeling on patient's trajectory or prognosis.
I'm often on point.
I don't say that out or arrogance, just experience.
A medically frail, advanced age, high comorbid chronically sick person won't do well after a code, if they survive.
Codes are messy.
There's lots of people surrounding your loved one. We are pressing hard and fast on likely frail ribs , trying to create a pressure environment to have blood return to the hard. This may be done with a machine (like a thumper) or manually by CPR trained providers. While the heart is being resuscitated, this happens in parallel with getting an airway, intubation. If you survive this, you will be on machines. ROSC , returning blood flow doesn't change the person before the code and it's worth all that "down time" is time blood didn't flow to the brain.
It's no grey's anatomy.
It's no gentle compressions with this bounce back of the person.
It's messy, it's traumatic, it's potentially harmful.
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So what do I want to walk away with, end with?
Dialogue. I think there should be an exchange of information between your doctor and you and your family. While some may view CPR and code status as an element of sustaining life and perhaps this is tied into spiritual , religious, personal beliefs, the medical part deserves to be shared.
There is an anxiety, a discomfort when the nurses, doctors, care team outside the room feel "oh man I don't really want to "code" this person and it's not going to go well" contrasted against a belief inside the room that a code may help or sustain life in a quality , patient centric way.
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