MD for DUMMIES

[CaLLaCoDe, BSN, RN]

The other day I thought there must be a book to help the helpless. You know how much the MDs count on us to report issues with our patients, humbly take orders and attend to them pronto. Well, here's the thing, wouldn't MD's to be just love a book that simply stated simple solutions to MD problems?

Example: Your patient is dying and the family is unwilling to have the patient's code status altered. What could you possibly say to convince the family that said patient doesn't deserve a tube to be jammed down his throat and potential rib cracking chest compressions delivered prior to leaving the facility upon being transferred to heaven.

Answer: We will do everything to help your dying Grandpa if you so desire it. His commotose state prolonged will ease all of your guilt. (Bottom line, prolong care to increase earnings)

[RNperdiem, RN]

It would be nice if there were simple solutions to those sort of problems. Unfortunately, sometimes family are not willing to hear what they do not want to hear. The doctor could get into graphic descriptions about what they can do, show the family what critical ICU patients look like, and it still wouldn't work. The family would just get angry with the doctor and demand that someone else look after grandpa. After all, grandpa is going to do just fine right? When is he coming home?

[RN1989]

I knew a doctor once that told the family "Fine. If you want him to have to die twice, that's your choice. But you are the one prolonging his suffering." Never saw his approach fail to get a DNR order agreed upon.

[TiredMD]

I knew a doctor once that told the family "Fine. If you want him to have to die twice, that's your choice. But you are the one prolonging his suffering." Never saw his approach fail to get a DNR order agreed upon.

I find statements like that unnecessarily cruel, although I know a lot of physicians think that they're doing the right thing by bullying family members into signing DNR orders they're not ready for.

I have never considered it our job to "convince" families to sign DNRs unless the patient has made it clear (in writing or verbally) that this is what they want. All this talk about "death with dignity" seems pretty silly to me; once your heart stops, you can crack all the ribs you want, stick them with needles, intubate, whatever. It's not hurting the patient.

Some families sleep easier thinking that they "did everything possible" to save Dad. Others sleep easier thinking that they "didn't prolong his suffering". Personally, I'm happy to oblige them either way.

[Elvish, BSN, DNP, RN, NP]

All this talk about "death with dignity" seems pretty silly to me; once your heart stops, you can crack all the ribs you want, stick them with needles, intubate, whatever. It's not hurting the patient.

It's torture.

[CaLLaCoDe, BSN, RN]

I find statements like that unnecessarily cruel, although I know a lot of physicians think that they're doing the right thing by bullying family members into signing DNR orders they're not ready for.

I have never considered it our job to "convince" families to sign DNRs unless the patient has made it clear (in writing or verbally) that this is what they want. All this talk about "death with dignity" seems pretty silly to me; once your heart stops, you can crack all the ribs you want, stick them with needles, intubate, whatever. It's not hurting the patient.

Some families sleep easier thinking that they "did everything possible" to save Dad. Others sleep easier thinking that they "didn't prolong his suffering". Personally, I'm happy to oblige them either way.

I find this thought process by Tired MD to be ironic being that he thinks it cruel to bully the family of the patient, nonsense. It's truth telling. Patients undergo tremendous trauma (mostly unwarranted) during a code.

And I find the idea of doing anything to a dead patient O.K. and by all means repulsive. Some of us aught to look for an other line of work with a cavalier attitude such as this! Hope he's not my doctor or my mothers!

Besides some belief systems such as Hindu believe that the body has several phases of death outside of vital signs alone...dignity is what all patient's deserve.

[TiredMD]

I find this thought process by Tired MD to be ironic being that he thinks it cruel to bully the family of the patient, nonsense. It's truth telling. Patients undergo tremendous trauma (mostly unwarranted) during a code.

And I find the idea of doing anything to a dead patient O.K. and by all means repulsive. Some of us aught to look for an other line of work with a cavalier attitude such as this! Hope he's not my doctor or my mothers!

Besides some belief systems such as Hindu believe that the body has several phases of death outside of vital signs alone...dignity is what all patient's deserve.

I never want families to feel like I forced them into withdrawing care for their loved one. Nor do I want them to experience the guilt of "pulling the plug" if they're not ready for it. I'm not really sure why that's such a terrible thing?

I can say with reasonable certainty that no heart beat = no blood flow to the brain = no pain sensation. So really, the things we do in codes don't actually hurt, unless the patient survives (which I think is a good thing). It's not "torture" unless it hurts, which is doesn't.

For my Hindu patients, or anyone else who wants to be DNR, I am more than happy to respect their wishes. That is, after all, what it's about, right? Respecting our patients' wishes? Be careful about letting your own preconceived notions about what constitutes "dignity" interfere with the care you provide.

[EmmaG, RN]

Our docs always respect the patients' and families' boundaries in this matter. No one is bullied or coerced, and yeah, we've coded patients who were terminal. Sometimes that is what the family needs, to know that they indeed did try everything possible. Sometimes they just haven't reached the level of acceptance and can't bring themselves to just allow their loved ones to die.

It's not up to us to make that call for them. Our job is to give them the information they need to make the decision, and then to support them in that decision.

Most of our patients choose to be a DNR once all treatments have been exhausted. But I've seen many delay making that decision for fear that we'll just "give up". One thing I make sure my patients and families know is that DNR does not mean "do not treat". We often will go all out, up to that point. And many are comforted in knowing that we will do so, and also that a DNR can be reversed if they so decide.

[TrudyRN]

It's torture.

I know where you're coming from but, as the other poster says, if they're unconscious and have no vital signs, they probably aren't feeling it anyway.

Frankly, I think we were better off before any of this (CPR), tube feeds, transplants, and the like, ever came into widespread use. But who can really say? Each case is different. And people are, I like to think, being dealt with by God on the issue of their eternal souls while they are this side of the grave.

Also, not to be disrespectful or morbid, but students learn a lot by practicing on corpses and others close to being corpses. It sounds harsh but we all know this is true - at least, where I went to school and have worked (teaching hospitals).

[Elvish, BSN, DNP, RN, NP]

Oh, I know that the person likely doesn't feel pain, but that still doesn't make me think it's ok to do all of the above to an 85yo pt with liver CA & mets to her brain, liver, and bone. That is part of the reason I could not work in these areas - just because someone's heart is beating and they are breathing does not mean they are alive. Clinically, yes, they're alive. And yes, I believe in eternal souls that God deals with too. But when do we give up and quit fighting Him and just let someone go?

It's a hard call.