John -- I completely agree with your opinion here. My view on is: "If you (or resident) are really skilled at cardiac resuscitation/ACLS you are probably poor at end-of-life discussions (and related documentation). As you've pointed out, futile care violates the ethic of "do no harm", but most clinicians feel compelled because of legal fears. --unless proper end-of-life discussions have been held with the patient or surrogate.
I hope you realize that none of this will matter if WHO gets it's revised health care treaty (the horror of horrors) and CBDCs are put in place. Then it will come down to your social credit score or how well you have prostrated yourself to the powers that be and their putrid desires that you comply with their sicko agendas.
The level of healthcare you receive or don't receive will be determined by a number. That number will include everything about you as that data is currently collected and has been collected for the last few decades by government and big tech and others. Your cell phone has been hijacked and many people have their lives intertwined with these menacing devices.
Your life or death while in the hospital, at any age for any reason, will be determined by your willingness to be a good little NAZI citizen.
I'm not convinced the EHR is the answer. IMO it should be automatic. Not having attended med school I can't be sure, but I imagine the baseline of all medical interventions is to cure/heal the patient. Part of treating a patient is knowing when to stop that type of treatment. It is NOT a failure if the body can not overcome the disease process or will end in a poor quality of life if continue to be treated. I was a liaison for hospice in an ICU. I would be brought in to discuss goals, prognosis, curative treatment, hospice with families. I can not tell you how many times families weren't told or were told and couldn't hear that their loved one is incurable or their loved one doesn't have months to live, they have days. I was the soothsayer. It was difficult.
If doctors, who by their very nature have a plethora of medical knowledge, can't or won't incorporate any alternative treatments other than curative then they should be working closely with someone who can. EOL is not a failure in itself or of the doctor or of medicine. It's the next step in medicine. We have MDs who learn and then become certified in this field.
It's not a surprise that many ICU, CCU, ONC nurses who change specialties come to hospice. They all say the same thing. I had moral injury daily from seeing and assisting in fruitless, unnecessary curative treatments given to frail souls whose outcome would remain the same with and without the treatment.
I'm proud to be on that bridge of change from treat with "that" to treat with "this".
I doubt putting a reminder in the EHR system will help. Palliative care needs to be brought in much sooner. My biggest regret is sending my husband to the hospital when he was sick. I should have let him die at home peacefully instead of going through that horror. But people always have to have hope. We need someone to tell us that if our loved one survives, they will not have much of a life anyways due to the damage an illness has done to their body. If we just look at them on the machines, we do not understand that the only thing keeping them alive are the machines.
The endpoint really should have been some measure of improved end-of-life care. You risk another bit of irritating admin that clusters up a doctor's day and reduces patient contact time.
Wouldn't it be more beneficial in terms of bottom line for a hospital or clinical setting to give false hope to a patient and continue with treatment especially if that patient has Medicare ? or really good private insurance? I'm fairly certain this happens more often than it should.
Pay the physician the equivalent to 2 days ICU cost AND extend the visit length so he/she can cover everything needed that visit and documentation. Focus on most likely scenario.
1. If physicians need a reminder, can't we reasonable conclude they have not been trained to do this and have not internalized the importance of the query. In other words, it is systematically embedded in the current state of medicine. A reminder treats a special cause (forgetful physician). But the problem is systemic, so different solution required.
4% increase. You can call that "statistically significant" (I haven't done math but I bet not at 99.7%) but is it actually meaningful? You're taking out a splinter in the finger, when a tourniquet for an arterial laceration in the forearm is required.
I'd be much more interested in investigating those that do the questions without needing to be prompted. The problem and solution lie upstream well before there is a patient in the situation.
2. "The real endpoint would be whether there were fewer patients suffering from non-beneficial care at the end-of-life."
The real endpoint is not suffering; the real-point is reducing and eliminating non-beneficial care whether at the end-of life or at any point.
You noted that you don't like to see suffering. Could be harsh here, but is reducing your suffering and uncomfortableness at seeing others suffering a legitimate concern? You are not the patient, the relatives are not the patients. Your and their suffering at seeing suffering is not the concern! The physician's duty is to the patient - no one else; the execution of the duty is to only provide "beneficial" care. The end point is the reduction of futile treatments. In situations of futility, anything other than palliative treatment is non-beneficial.
What is futility? 🤷♂️ If physicians are comfortable operationalizing hypertension or obesity or high cholesterol, then they ought to give operationalizing "futility" some effort.
As noted, this was a surrogate endpoint. Just as statins lowering LDL is all fine and good, but we needed to know that they improved survival and other CV outcomes, so too this intervention will need to show a benefit on end of life QoL. But this is certainly a good start.
Too many times we get very old and frail pts in CCU and we are treating them no differently than a 60 yo with an ACS, and I’m left asking “what are we doing here?” And sure, we try to have “code” discussions for all admissions, but this discussion and the necessary contemplation on the part of pts and families needs to occur long before they reach the door to the ER.
The problem is exacerbated by unrealistic expectations on the part of patients, their loved ones, sometimes their physicians and by the compartmentalization of care, particularly in-patient. Multiple specialists address their areas but no one advocates for the patient. On many occasions when caring for my patients clearly near the end of life, still receiving aggressive and likely futile care, I reminded them they were in charge and encouraged them to discuss the goals of treatment or stopping treatment with all their physicians. I sometimes called those physicians to give them a heads up.
When my father was near the end of his life, at 95 years old, with progressive dementia, he was hospitalized once again, this time with hematuria caused by an recurrent bladder tumor and his anticoagulation for a fib. I learned he was increasingly confused, at times combative, and in pain. I flew home to see him, found him with an IV, restrained. He had a poorly functioning Foley catheter, the source of his pain and agitation, bloody urine draining from and around the catheter. I called the urologist and asked him to remove the catheter, called the cardiologist and asked him to stop the DOAC, called his internist and asked him to remove the restraints and edit his med list, and with my family, arranged for him to return to the familiar surroundings of his home where he was fortunate to receive excellent supportive care and where he subsequently died.
Those of us in medicine have looked behind the curtain, we often know too well when care is futile. We have the ability to advocate for ourselves and our loved ones for aggressive care when appropriate and when to step back. For most people, that type of informed advocacy is lacking.
As a surgical intern at a major, Ivy League hospital in 1988, I attended a Saturday morning presentation by a guest trauma surgeon, who presented statistics that showed that an ICU admission for a medical (non-surgical) patient with 2 or more failing organ systems carried a 100% mortality rate for that hospitalization. ICUs were developed to facilitate treatment for acute, life-threatening medical problems with a reasonable chance of recovery. It amazes me that 30+ years later, ICU admissions are still used for chronically ill patients as a futile "last-ditch effort" simply because no frank conversation with the patients and their families have occurred, or the physician's judgment is supplanted in favor of uninformed, unrealistic "patient wishes." As budgets are tightened, these issues may finally be addressed, but I fear that having the ICU beds available will still result in them being used for these unfortunate victims of modern medicine, whose bodies are poked, prodded, and invaded in their last, undignified hours and days.
This needs to be discussed with the patient way in advance and should include family members who will have a say in the patients care. Way too many times I’ve heard from family “We are going to do everything for momma until gods’ hand takes her away”.
That’s called unplugging the machine.
Let’s not forget those wonderful lawyers floating around eagerly awaiting to sue for wrongful death.
Advanced directives are not appropriately queried. When my parents went into long term care it was asked if they wanted to be resuscitated and if they wanted advanced life support. That bimodal question is improper. If one of them fell and hit their head on the stairs the first week then yes, but if they develop renal failure over the next 30 months then go into failure no. The decision on how you respond to a heart stoppage depends mostly on how you got there. Thus the questions asked need to consider that. Doctors know the chances of recovery for elderly based on what got them to the point of need resuscitation and they need to classify them and then give the patients signing a directive yes no responses to a set of maybe 3-4. A family member with power of attorney need also to be present for this discucssion.
John -- I completely agree with your opinion here. My view on is: "If you (or resident) are really skilled at cardiac resuscitation/ACLS you are probably poor at end-of-life discussions (and related documentation). As you've pointed out, futile care violates the ethic of "do no harm", but most clinicians feel compelled because of legal fears. --unless proper end-of-life discussions have been held with the patient or surrogate.
I hope you realize that none of this will matter if WHO gets it's revised health care treaty (the horror of horrors) and CBDCs are put in place. Then it will come down to your social credit score or how well you have prostrated yourself to the powers that be and their putrid desires that you comply with their sicko agendas.
The level of healthcare you receive or don't receive will be determined by a number. That number will include everything about you as that data is currently collected and has been collected for the last few decades by government and big tech and others. Your cell phone has been hijacked and many people have their lives intertwined with these menacing devices.
Your life or death while in the hospital, at any age for any reason, will be determined by your willingness to be a good little NAZI citizen.
I'm not convinced the EHR is the answer. IMO it should be automatic. Not having attended med school I can't be sure, but I imagine the baseline of all medical interventions is to cure/heal the patient. Part of treating a patient is knowing when to stop that type of treatment. It is NOT a failure if the body can not overcome the disease process or will end in a poor quality of life if continue to be treated. I was a liaison for hospice in an ICU. I would be brought in to discuss goals, prognosis, curative treatment, hospice with families. I can not tell you how many times families weren't told or were told and couldn't hear that their loved one is incurable or their loved one doesn't have months to live, they have days. I was the soothsayer. It was difficult.
If doctors, who by their very nature have a plethora of medical knowledge, can't or won't incorporate any alternative treatments other than curative then they should be working closely with someone who can. EOL is not a failure in itself or of the doctor or of medicine. It's the next step in medicine. We have MDs who learn and then become certified in this field.
It's not a surprise that many ICU, CCU, ONC nurses who change specialties come to hospice. They all say the same thing. I had moral injury daily from seeing and assisting in fruitless, unnecessary curative treatments given to frail souls whose outcome would remain the same with and without the treatment.
I'm proud to be on that bridge of change from treat with "that" to treat with "this".
I doubt putting a reminder in the EHR system will help. Palliative care needs to be brought in much sooner. My biggest regret is sending my husband to the hospital when he was sick. I should have let him die at home peacefully instead of going through that horror. But people always have to have hope. We need someone to tell us that if our loved one survives, they will not have much of a life anyways due to the damage an illness has done to their body. If we just look at them on the machines, we do not understand that the only thing keeping them alive are the machines.
The endpoint really should have been some measure of improved end-of-life care. You risk another bit of irritating admin that clusters up a doctor's day and reduces patient contact time.
Wouldn't it be more beneficial in terms of bottom line for a hospital or clinical setting to give false hope to a patient and continue with treatment especially if that patient has Medicare ? or really good private insurance? I'm fairly certain this happens more often than it should.
Pay the physician the equivalent to 2 days ICU cost AND extend the visit length so he/she can cover everything needed that visit and documentation. Focus on most likely scenario.
1. If physicians need a reminder, can't we reasonable conclude they have not been trained to do this and have not internalized the importance of the query. In other words, it is systematically embedded in the current state of medicine. A reminder treats a special cause (forgetful physician). But the problem is systemic, so different solution required.
4% increase. You can call that "statistically significant" (I haven't done math but I bet not at 99.7%) but is it actually meaningful? You're taking out a splinter in the finger, when a tourniquet for an arterial laceration in the forearm is required.
I'd be much more interested in investigating those that do the questions without needing to be prompted. The problem and solution lie upstream well before there is a patient in the situation.
2. "The real endpoint would be whether there were fewer patients suffering from non-beneficial care at the end-of-life."
The real endpoint is not suffering; the real-point is reducing and eliminating non-beneficial care whether at the end-of life or at any point.
You noted that you don't like to see suffering. Could be harsh here, but is reducing your suffering and uncomfortableness at seeing others suffering a legitimate concern? You are not the patient, the relatives are not the patients. Your and their suffering at seeing suffering is not the concern! The physician's duty is to the patient - no one else; the execution of the duty is to only provide "beneficial" care. The end point is the reduction of futile treatments. In situations of futility, anything other than palliative treatment is non-beneficial.
What is futility? 🤷♂️ If physicians are comfortable operationalizing hypertension or obesity or high cholesterol, then they ought to give operationalizing "futility" some effort.
As noted, this was a surrogate endpoint. Just as statins lowering LDL is all fine and good, but we needed to know that they improved survival and other CV outcomes, so too this intervention will need to show a benefit on end of life QoL. But this is certainly a good start.
Too many times we get very old and frail pts in CCU and we are treating them no differently than a 60 yo with an ACS, and I’m left asking “what are we doing here?” And sure, we try to have “code” discussions for all admissions, but this discussion and the necessary contemplation on the part of pts and families needs to occur long before they reach the door to the ER.
The problem is exacerbated by unrealistic expectations on the part of patients, their loved ones, sometimes their physicians and by the compartmentalization of care, particularly in-patient. Multiple specialists address their areas but no one advocates for the patient. On many occasions when caring for my patients clearly near the end of life, still receiving aggressive and likely futile care, I reminded them they were in charge and encouraged them to discuss the goals of treatment or stopping treatment with all their physicians. I sometimes called those physicians to give them a heads up.
When my father was near the end of his life, at 95 years old, with progressive dementia, he was hospitalized once again, this time with hematuria caused by an recurrent bladder tumor and his anticoagulation for a fib. I learned he was increasingly confused, at times combative, and in pain. I flew home to see him, found him with an IV, restrained. He had a poorly functioning Foley catheter, the source of his pain and agitation, bloody urine draining from and around the catheter. I called the urologist and asked him to remove the catheter, called the cardiologist and asked him to stop the DOAC, called his internist and asked him to remove the restraints and edit his med list, and with my family, arranged for him to return to the familiar surroundings of his home where he was fortunate to receive excellent supportive care and where he subsequently died.
Those of us in medicine have looked behind the curtain, we often know too well when care is futile. We have the ability to advocate for ourselves and our loved ones for aggressive care when appropriate and when to step back. For most people, that type of informed advocacy is lacking.
A tragic effect of the corporate takeover of hospitals and health care. Pad the bill, regardless of need, benefit, or suffering.
There are many ways of having the goals of care discussion. But, there are many limitations:
-I want to live doctor
-Dad was a fighter
-A family member that comes out of nowhere who swears that the patient said "I want to live"
-Religious fervor
-Wife that overturns the DNR as soon as mental status makes the patient incompetent for medical decisions
-Oncologist says that this 5th line of chemotherapy where I have a chance of finally getting better
And these just popped in my head in 1 min. List can get quite longer if you give a little more time
As a surgical intern at a major, Ivy League hospital in 1988, I attended a Saturday morning presentation by a guest trauma surgeon, who presented statistics that showed that an ICU admission for a medical (non-surgical) patient with 2 or more failing organ systems carried a 100% mortality rate for that hospitalization. ICUs were developed to facilitate treatment for acute, life-threatening medical problems with a reasonable chance of recovery. It amazes me that 30+ years later, ICU admissions are still used for chronically ill patients as a futile "last-ditch effort" simply because no frank conversation with the patients and their families have occurred, or the physician's judgment is supplanted in favor of uninformed, unrealistic "patient wishes." As budgets are tightened, these issues may finally be addressed, but I fear that having the ICU beds available will still result in them being used for these unfortunate victims of modern medicine, whose bodies are poked, prodded, and invaded in their last, undignified hours and days.
This needs to be discussed with the patient way in advance and should include family members who will have a say in the patients care. Way too many times I’ve heard from family “We are going to do everything for momma until gods’ hand takes her away”.
That’s called unplugging the machine.
Let’s not forget those wonderful lawyers floating around eagerly awaiting to sue for wrongful death.
Advanced directives are not appropriately queried. When my parents went into long term care it was asked if they wanted to be resuscitated and if they wanted advanced life support. That bimodal question is improper. If one of them fell and hit their head on the stairs the first week then yes, but if they develop renal failure over the next 30 months then go into failure no. The decision on how you respond to a heart stoppage depends mostly on how you got there. Thus the questions asked need to consider that. Doctors know the chances of recovery for elderly based on what got them to the point of need resuscitation and they need to classify them and then give the patients signing a directive yes no responses to a set of maybe 3-4. A family member with power of attorney need also to be present for this discucssion.