A Living Will is a document prepared with the assistance of an attorney. This document states in advance your wishes about life-sustaining treatment when you are terminally ill, permanently unconscious or in the latter stages of a fatal illness.
It also selects who you want to speak on your behalf. This document deals with persons who have end of life illnesses and what efforts are to be undertaken. They do not require the patient's signature. A DNI order means that while the physicians may use chest compressions and cardiac drugs, no breathing tube will be placed in the patient. The two are separate because you can have trouble breathing before your heartbeat or breathing stops.
In most cases, a "do not resuscitate" order alone might stop a medical team from pursuing further intervention. But this man, unlike many patients in the intensive care unit who were clearly close to dying, had walked into the hospital for an elective diagnostic work-up. As of that morning, he was not close to dying, and even within moments of starting CPR, we felt reasonably certain that we could resuscitate him. My senior resident astutely directed me to figure out who Mr.
R had listed as his health care proxy, his stand-in medical decision-maker. We needed to make sure that Mr. R would not want us to do any more. The proxy was his son, who lived in another state. When I called to check about his father's wishes, his answer was unequivocal: "My father would want everything done to save his life. Minutes later, we regained a pulse and Mr. R was sent to the intensive care unit, where he was temporarily intubated on a ventilator for a few hours.
I asked him again about whether he would want to be resuscitated or intubated if needed to keep him alive. He said he would, so long as it would not mean a life permanently dependent on a machine. He walked out of the hospital two days later, knowing that he had almost died. The resident led the discussion, but I wanted to be sure to explain that most patients tolerate blood transfusion well but in rare cases, they have a reaction and require ventilation.
How do you broach the subject? For patients admitted with pneumonia, I begin by asking if they have a health care proxy, living will or advance directive because that will guide a lot of the discussion. Those who have one have thought a bit about it. What do you say then? Rarely, it gets bad enough that they require ventilation, being on a breathing machine. What do you know about that?
What does that mean to you? Who else can help? Much of the criticism about how hospitalists talk about code status is that we jump into it without getting the idea of patient goals beforehand. When we wrote the JHM paper, my colleagues and I agreed that the discussion ought to be framed around goals, and only then should we make a recommendation and come to a consensus.
Thursday, November 11, Today's Hospitalist. Streamlining admission decisions. Big payoff for performance feedback. Recent articles. Tips for negotiating compensation May
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