Thursday, July 29, 2010

An inspiring addendum to Gawande's piece for physician researchers

Check out this new Huffington Post piece by Aaron Carroll, inspired by Gawande's Neworker article "Letting Go."  Carroll and Gawande's articles reminded me of a one of the most frustrating moments in residency.

I remember near the end of residency talking with other third year residents about things they were most proud of. Everyone else talked about the heroic "saves": diagnosing tamponade, recognizing aortic dissection. I remember feeling strangely guilty, but I was most proud of leading a family discussion for a patient w/end--stage CHF who had been re-hospitalized numerous times that led him to enroll in hospice.

Conversely, the most frustrating moment of residency was when I could not make the system honor a patient and family's wishes. As a second year resident, I got called down to admit a nursing home patient to the ICU for pnuemonia and respiratory failure. The nursing home noticed she was having difficulty breathing, called 911, EMT's whisked her to the ER, where she was promptly intubated. I think I was the first person to look at the packet that arrived from the NH, where it clearly stated she was DNR/DNI. Looking at the notes more carefully, I remember that she had fairly advanced dementia, and did not recognize family members anymore, and the decision had been made ~1y ago that although antibiotics and brief hospitalizations were OK, intubation was not supposed to happen.

Even though it was 1am or so, I called the niece DPOA, and explained the situation. She was not upset, but given the gravity of the clinical situation, we agreed that she should come in and we should figure out how we can re-focus her care toward comfort. After I spoke with her, but before she got in, I spoke w/the ER attending, who was not thrilled to hear that he had intubated a patient who was DNI and that I wanted to extubate the patient and focus more on comfort. He told me categorically, "You're not doing that here." So we got her admitted to the ICU where the ICU anesthesia fellow told me that she would not be extubated. He felt that any discomfort she had was during the process of intubation, and that now she was comfortably sedated. I found out later that the usual practice is that an attending is needed for extubation and that the fellow did not want to call the attending in for an extubation in the middle of the night. The niece came in soon thereafter and the ICU fellow and I relayed that she seemed to be comfortable now so our recommendation was that she remain intubated until morning.

I remember being intensely frustrated because it felt like despite my best efforts, the system had a will of it's own, and it was set on forcing aggressive care to those who do not want it and would not benefit from it. I remember thinking about calling in my attending and deciding against it because I wondered how much of my frustration was because my plans had been subverted. Maybe the ICU fellow was right--she probably was not particularly uncomfortable and she had already paid the costs of aggressive care and extubating her wouldn't have undone the discomfort already suffered.

The next morning was the end of the month, so I moved onto another hospital. I heard that the niece came back and was convinced to keep her intubated. The patient did not improve significantly, so was extubated and died several days later.

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