Good Practice (a parody of Green Day’s “Good Riddance”)

Must-see for all health care providers. Need I say more?

DNR 104

We’re at the residence of an elderly gentleman. His family has all his medical items organized so well it’s as if we’re at a pharmacy.

But they can’t find his DNR.

Luckily we don’t need it. Rather, I’m using this as opportunity to make sure they have everything all squared away. Every old or chronically ill person I go to, I’m taking the time, no matter what the call is, to make sure either the patient or the family has the DNR ready to go, if that is what they want.

They have the DPA paperwork though.

Durable Powers of Attorney for health care decisions are useful for most situations, but in general it has the disadvantage of requiring that the attorney(s)-in-fact be physically present on the scene to make any actual decisions. For instance, the only other person on this scene on this day is not listed among the 3 attorneys-in-fact on the DPA, and therefore has no legal standing to make any health care decisions. So if this was a CPR call, no one would be available to refuse the resuscitation on behalf of the patient. A DNR has no such requirement. It is specifically for refusing CPR. It is only valid when a patient is pulseless and not breathing. It means nothing else.

If this hyper-organized family can’t get the DNR right, how can we expect anyone else to?

So, my dear patients and family members, I want you to approach it the way we, EMS people, do. Imagine for a moment that you are us, and you’re walking into someone’s home. They called 911 because their family member is pulseless and not breathing. Their family member has also made it perfectly clear that there is to be absolutely no CPR. How do you suppose they’re going to stop you from starting a resuscitation?

That’s easy – they should shove the valid DNR right in your face.

A less direct approach is to point to the DNR tacked to the wall over the patient’s bed. Or taped to the fridge. Better yet, put it all over the place. Make it the wallpaper pattern.

The goal is to show responding crews a valid DNR before we open a single bag, so, how do you do that? By keeping copies of the DNR everywhere. If the patient is the ambulatory sort, put a copy in his pocket or around his neck.

If you have to go look for it, I guarantee that you won’t find it before the monitor gets turned on, and the resuscitation starts. And the patient’s wishes are not honored.

It’s the last wish, and it’s not honored.


A good investment (I hope)

The other day we spent 30 minutes at the residence of a 40-year-old woman with a history of anxiety attacks* who had an anxiety attack. Despite my intense distaste for anxiety attacks and the people who ridiculously involve 911 when they have them, I patiently coached her out of it, tried my best to explain every little detail about how to keep it in check to her and her willing family, and even managed to slip in there a reminder to her daughters that being good kids meant not upsetting Mom.

“Why did you spend all that time there?” My partner asked.

Well, that’s simple – if I can keep them from calling us again for something like that, I’d do as much as I can to make it so. Someone has an anxiety attack, calls 911, gets transported to the ED while every provider is thinking what a dumb call it is, comes home after being discharged within an hour or two, has another anxiety attack some days later and the cycle starts all over again. The only way this cycle has any chance of being broken is when people take the time to show them there’s a better way.

Or, as a co-worker likes to say when dealing with idiots, “Your way doesn’t seem to be working for you at all, does it?”

It’s not that different than the time I take to explain advance directives to patients and their families. There is a better way to manage end-of-life decisions, but no one has shown them. (And once again, thanks, Sarah. You’re a tool.)

Besides, they loved us. For not laughing in their faces. For not rolling our eyes. For taking the time and effort to fix their problem. For answering their questions. For agreeing that chocolate milk tastes good. That was some PR that no money can buy.

*Anxiety attacks and the like are generally diagnoses of exclusion. Your bosses may say that everyone with similar symptoms needs to be transported. I used some discretion and a little experience. And some common sense. Everyone was happy. Especially the ED, who didn’t have to see her.

DNR 103

Certain segments of our society have once again begun to spread the “Death panels” lie as a way to start the new year. And in response, it appears that the government has caved to this horseshit after initially trying to do the right thing. Again.

Thanks, liars. I am so sick of going to call after call after call where people who should have discussed death never discussed death. People and their families who for whatever reason did not plan their end-of-life options are having the worst day of their lives, and somehow you liars, by flat out lying about an important part of dying and thereby discouraging people from the absolutely necessary end-of-life planning, are contributing to making that day even worse, if that’s even possible.

Anyway, my dear sane and honest people, please spread the word: “Death panels” were PolitiFact’s 2009 Lie of the Year.


DNR 102

Perhaps it’s modern medicine that has led people to falsely believe that everything is treatable and even curable, and in turn, no one gives death – and all the arrangements it entails – the attention it deserves, not prior to death anyway. With Elizabeth Edwards’ passing, I hope patients everywhere can find some lessons in this event and seriously consider their health care choices.

CNN: Elizabeth Edwards made wise choice to go home

NYT: Lessons from Elizabeth Edwards

With the far right’s artificial national hysteria over end-of-life counseling out of the limelight, I sincerely hope that patients are encouraged to consult with their health care providers and their families, think about their illness(es) realistically and make detailed plans for the inevitable. It’s not productive at all for family members to discuss argue about end-of-life options when we’re arriving on scene or when they’re screaming in the ED lobby for help.

I’ve written about end-of-life issues many times, as it is very painful to watch every single time it is neglected before it’s too late:

AICD: Apparently I Can’t Die

Nope, not just yet.

Since end-of-life counseling sucks around here, here’s something else to further depress you. In addition to frequently not getting information and guidance on advance directives, there are terminal patients who aren’t getting their automated implantable cardioverter-defibrillators (AICD) turned off in a timely fashion. Talk about dying without dignity.

DNR 101

Over the last year or so during the health care debate, thanks to politicians’ and pundits’ hysterical fear-mongering, Do-Not-Resuscitate (DNR) orders, along with other advance directives used in health care, took a few steps back in its vain quest for a little bit of respect and recognition from the general public. Besides, how can we expect the general public to understand a DNR when even doctors and nurses don’t understand it? And how can we even try to show people the facts when there are people out there deliberately distorting end-of-life issues?

On a related note, why is it OK to put our pets down to end their suffering but somehow it’s automatically and unequivocally wrong, as some claim, to do the same for our family members?

Put in the simplest terms, with a valid DNR, a patient without spontaneous breathing or a pulse is not resuscitated; in other words, we “let them go.” A DNR is only valid if the patient is pulseless or apneic; it is meaningless otherwise.

Many providers mistakenly view a DNR as an excuse to not initiate treatment, even treatment as simple as fluids or relieving an airway obstruction. That is very wrong.

Some patients actually think we will smother them with a pillow if they have a DNR (I’m not making this up) but that cannot be farther than the truth. Many patients who should at least consider getting a DNR don’t get one. I’m not saying everyone should get one, but many people don’t even want to think about and plan in advance their end-of-life decisions, and that is foolish.

As I’ve mentioned before, primary-care physicians have to bear a lot of responsibility for this phenomenon. If I have to explain advance directives to someone on a call, it is way too late. These days I’ve been actively trying to discuss end-of-life issues with certain still-living patients and their families whenever the appropriate opportunity arises.

How many times do we go to a cardiac arrest call only to have the family beg us not to start the resuscitation (“That’s not what my grandmother wants!”) but they don’t have any paperwork declaring those wishes?

How many times do we go to the same call only to have everyone fighting over what the patient’s wishes actually were, also without any paperwork declaring such wishes?

How many times do we go to the same call only to find that nobody has any idea where the valid DNR form is in the house?

How many times have you seen a family member, for his or her own selfish reasons, insist on a resuscitation over the objections of everybody else on the scene?

You think MCIs are dramatic? Try these scenes I just mentioned.

The simple fact is this: get your paperwork in order, and we will respect your wishes no matter what your wishes are.

All we’re asking for is the following:

  • please, please, please think long and hard about what your end-of-life choices are
  • discuss them clearly and intelligently with your family
  • make them understand the importance of respecting your wishes
  • put these wishes on paper

And, for those who haven’t seen this: the POLST form, sort of a “DNR on steroids.”