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Posted by Guest Blogger on May 22, 2012
Early on in her medical residency years, Lauren Jodi Van Scoy, MD, developed an interest in critical care with a focus on end-of-life issues. She wrote Last Wish: Stories to Inspire a Peaceful Passing (Volume 1) In addition to personal stories of people facing end-of-life decisions, Dr. Van Scoy includes a tear-away discussion guide, the Compass, to help individuals talk about and determine what they'd want if they end up in a life threatening situation or land in the ICU. Below is an excerpt from Dr. Van Scoy's book, reprinted with permission.
Dr. Olson held her breath. This was the DNR decision, whether or not to give the doctors the instruction, "do not resuscitate." She felt strongly that resuscitating Victoria, or coding her, would be overly aggressive, and she imagined herself having to do chest compressions or shocks and threading long IV catheters into Victoria's groin as was common during a code. She hoped with all hope that they said no.
"Well, if it happened before you got her off the ventilator and you restarted her heart, we might still be able to talk to her, so I think you should at least try," Sara said quickly.
Dr. Olson's heart sank. Sara, she suspected, was imagining CPR like she's seen on television, the kind where the patient receives CPR and before the show is over the patient is up chasing bad guys or whatever the case may be. It's an overly optimistic view. Never during these shows do they depict the central line being stuck into the groin to administer the code medications. It never shows the ventilator being placed, which must always occur with CPR. They don't show the red scorch marks where the shocks are delivered to the chest, nor do they play the sound of the ribs cracking. Never do they address the high likelihood of brain damage if CPR continues for a long period of time, and how we sometimes begin a post-cardiac arrest period of hypothermia to reduce the likelihood of brain damage. Typically, hypothermia comes with a twenty-four hour period when the body is chilled down to temperatures so cold that paralytic medications are used to prevent the violent shivering that results. Television and media often neglect to address these realities.
"For some patients, Sara," Fred began, "CPR can be quite successful. But in patients with end-stage, terminal conditions, the chances of it helping, rather than hurting, is incredibly low. My honest opinion is that CPR would do nothing except prolong the period in which your mother is dying, and wouldn't put us any closer to our goal of getting her off the ventilator."
"No CPR, no shocks," Lana said. "If it's going to restart her heart just to keep her alive like this, then I don't see the point."
Dr. Olson looked around to try and get a feel of what the crowd thought of Lana's decision. Sara had buried her face in her hands for a moment, but then nodded in agreement..
Fred continued. "I think that's a really reasonable and appropriate decision, Lana. From here we can do one of two things in regards to getting her off the ventilator. We can take her off today, with morphine to control any pain or shortness of breath, or we can give it a few days and see if we can wean her gradually and see how she does."
It was at this point in the meeting that Dr. Olson saw the stoic faces begin to really react to the information. Twisted faces and tears filled the room whilst arms came from seemingly nowhere to embrace each other. Sara leaned onto Lana, who kept her eyes on Dr. Olson, whose facial expression kept her at ease. Lana could feel Dr. Olson comforting her silently, and Lana knew Dr. Olson would be there to help her face the looming decisions.
"It's possible that we could get her off the ventilator with just a few days of weaning trials," Dr. Bernstein said. "She'd have to have a nice slow breathing rate and we'd have to lift the sedation to make her alert enough to breath on her own before taking the tube out, but it's also possible that we won't be able to remove the sedation easily if the pain causes her to breathe fast or panic. It can be challenging, and sometimes a lengthy process, especially in situations like these. It's really up to you to think about what duration of life support, if any, you think your mom would agree to."
"And if we took her off today, she'd probably die today?" asked a woman in the back.
"Probably," Dr. Olson said gently, "although, it's hard to know for sure. She isn't ready to breath on her own yet, but if we took the tube out, we'd use the medications to keep her comfortable and pain-free. Perhaps she'd wake up after the tube came out and we fine-tuned her medications, but there's a chance she wouldn't. It's hard to say. Either direction you choose, we would do everything we could to limit her discomfort."
"I hear what you're saying. I just...well..." Lana gathered her thoughts. "I guess we will need a little time as a family to discuss it and decide...I mean, we want her off the machine. I just don't know if we're ready to do it today." Lana's eyes searched Dr. Olson's face as if looking for some sort of hint as to what she should do.
"By all means, take some time to yourselves," Dr. Bernstein answered. "And if you want to talk more, Dr. Olson and I will be in the unit."
Lana nodded as the doctors stood to leave. Dr. Olson lingered for a moment because she felt awkward leaving Lana behind. "I'll be right outside if you have any questions." She looked straight at Lana.
Dr. Olson slipped out of the room and the door clicked quietly behind her. Sobs erupted as she walked away from the meeting room, and she headed back to the unit to sit and wait for their decision.
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