Full Code Hospice Pt Acute Change in Condition...What to Do?

Specialties Geriatric

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Last night I had a hospice resident who also happens to be a full code. This individual presented with an acute and significant change in condition. Primary Dx mets cancer. He presented with sudden decreased LOC, unable to follow simple commands, one sided facial drooping and could not grasp at all with that same side. Also unable to swallow. Acutally, seemed unaware that there was anything to swallow when a cup was placed on his lips. He was staring off into space and would occasionally offer one-syllable responses when prompted after several attempts. VS's were stable in otherwise no acute distress. I sent him out after speaking with his hospice nurse citing the code status. I was unable to reach family for their input. He looked mighty CVA-ish to me. However, with the mets and not being a MD with all the fancy equipment I can not rule out a brain mets that caused the acute change. Either way, I did not feel comfortable with the situation at all and erred on the side of caution and obtained the order to send out. What would you have done or have done under similar circumstances?

Specializes in critical care, ER,ICU, CVSURG, CCU.
I need sources for this sweeping statement.

ethics.va.gov

ama-ethics medically futile

ncbi.gov

all deal with physician declaration medical futile

Specializes in critical care, ER,ICU, CVSURG, CCU.

ooooops you may have meant that 0% chance of benifit....... my bad:roflmao:

Sally, I have no problem with knowing that ethics statements have been made. But these are not links to laws.

Physicians do not have a responsibility to pro... [Crit Care Med. 1995] - PubMed - NCBI

"[h=4]CONCLUSIONS:[/h]Although the issue of physician refusal of requested care has not been resolved by case law or legal statute, it is supported by compelling ethical principles. Physicians are not ethically required to provide futile or unreasonable care, especially to patients who are brain dead, vegetative, critically or terminally ill with little chance of recovery, and unlikely to benefit from cardiopulmonary resuscitation.

Specializes in Critical Care.
That is not what she said. And as I said earlier, and you ignored, here in TX the physician does not get to choose not to perform CPR. You imply that to refuse futile care is simple, and not fraught with litigation. Further, your attitude reeks of hubris.

There is a process required in Texas to withhold lifesaving treatments due to medical futility. If the patient or family objects, they can request an ethics consult. If the ethics committee holds up the Physician's decision, then the patient or family can attempt to find an accepting facility to transfer to, if this cannot be done, then the Physician can unilaterally order that lifesaving treatments be withheld.

This comes from the Texas Advanced Directives Act of 1999. There are currently some modifications to this being proposed to better define this specifically for DNR rules, but just as in any state, so long as Physicians follow the steps required, they can order that medically futile treatments be withheld.

In terms of hubris, hubris is the overestimation of one's abilities despite evidence to the contrary, it's hubris that caused the need to address and reel in the role of CPR and codes; we believed we were so powerful that we could reverse an unstoppable natural process, even in situations where the evidence is to the contrary.

Specializes in Critical Care.
Physicians do not have a responsibility to pro... [Crit Care Med. 1995] - PubMed - NCBI

"CONCLUSIONS:

Although the issue of physician refusal of requested care has not been resolved by case law or legal statute, it is supported by compelling ethical principles. Physicians are not ethically required to provide futile or unreasonable care, especially to patients who are brain dead, vegetative, critically or terminally ill with little chance of recovery, and unlikely to benefit from cardiopulmonary resuscitation.

As the link I posted earlier noted, our knowledge and resulting views on resuscitation as well as legal precedents have changed significantly since the 90's, you'll notice your link above is from 1995.

Most of our current knowledge of who can benefit from CPR, and who can't, really began in 2004. The same linked article discusses the myth that Physicians are at a disadvantage in court if they unilaterally decide to withhold lifesaving treatment.

There is a process required in Texas to withhold lifesaving treatments due to medical futility.

Only for Medicaid patients. I am familiar with the act.

Specializes in Critical Care.
Only for Medicaid patients. I am familiar with the act.

The act applies to patients regardless of insurer.

The act applies to patients regardless of insurer.

Incorrect. But I will bow out. Your idealism is at odds with the legal system.

Specializes in Critical Care.
Incorrect. But I will bow out. Your idealism is at odds with the legal system.

Here is the full text of the act. Some Federal laws only apply to facilities that bill medicare or medicaid, although even then these laws apply to every patient in these facilities, not just those under medicare or medicaid.

It's not my idealism, although I happen to agree with it for the most part, I've explained, and provided references as to what the prevailing view, both ethically and legally, is on the role of the Physician in writing code orders. Yet I've yet to see anything to disprove that.

To give an example of how this works in practice, I had a patient with a near circumferential abscess of the annular ring of their aortic valve, meaning their aortic valve was about to break free, essentially producing a very bad wide-open aortic stenosis. It was inoperable. We knew it was about to come loose and that CPR wouldn't do anything. Family wanted everything done, yet since coding the patient offered absolutely no potential benefit the Physician didn't order that non-beneficial treatment. You think he should have?

Specializes in LTC.
Here is the full text of the act. Some Federal laws only apply to facilities that bill medicare or medicaid, although even then these laws apply to every patient in these facilities, not just those under medicare or medicaid.

It's not my idealism, although I happen to agree with it for the most part, I've explained, and provided references as to what the prevailing view, both ethically and legally, is on the role of the Physician in writing code orders. Yet I've yet to see anything to disprove that.

To give an example of how this works in practice, I had a patient with a near circumferential abscess of the annular ring of their aortic valve, meaning their aortic valve was about to break free, essentially producing a very bad wide-open aortic stenosis. It was inoperable. We knew it was about to come loose and that CPR wouldn't do anything. Family wanted everything done, yet since coding the patient offered absolutely no potential benefit the Physician didn't order that non-beneficial treatment. You think he should have?

I can see both sides of that situation. On the one hand, it was obvious that no heroic life-saving measures would have saved that pt. On the other hand, the family may have needed to know that "everything" was done to try to save their loved one so that they could let go and accept his loss. Without him/her having CPR performed, they may always question whether or not the pt may have been saved and remain unsettled at the loss. That's pure speculation, of course. Tough situation to be sure.

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